Please fill out the form below to apply to attend the "Identity and Ancestry" Workshop. Current SECTION A - Personal Information SECTION B - Questionnaire Complete First Name Last Name Address Address City/Town Province - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code Preferred Phone Number Type of preferred phone number: - Select -Cell PhoneHome PhoneWork PhoneOther Secondary Phone Number Type of secondary phone number: - None -Cell PhoneHome PhoneWork PhoneOther Personal Email Job Title Employer Work Site Name HEU Local (if known) Employment Status Full-time Part-time Casual Region North Interior Vancouver Coastal (includes PHSA) Fraser Vancouver Island Do you identify as a member of any of the following equity groups or as a young worker? 2SLGBTQIA+ Indigenous Persons with disabilities Worker of Colour 2-Spirit, Woman, or Non-Binary Young Worker (33 years or younger) None Prefer not to say We are collecting this information to ensure we have diversity at our event. This information will be kept confidential. Emergency contact name Emergency contact phone Do you have any medical condition(s) or is there anything else that we should be aware of that could impact your ability to participate in this event? Yes No If yes, please briefly explain. (In some cases, a physician's note may be required). Do you have any accessibility requirements (i.e. ergonomic chair)? Yes No If so, please specify:
