Apply Now Interested in volunteering in Winnipeg as a JSMP? Apply using the formApply Now JSMP Winnipeg & Surrounding Area Program Application Form Please fill this form to register for the Junior Staff Mentorship Program in Winnipeg. Step 1 of 6 16% PARTICIPANT INFORMATIONParticipant First Name* First Name Participant Last Name* Last Name Preferred namePreferred Pronouns (If Any)Date of Birth* Age*School Currently Attending*Grade9101112Gender* Female Male Non-Binary Prefer Not To Disclose Other (Please Specify) Other*Participant Home Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PARTICIPANT DEMOGRAPHIC INFORMATIONCareer Trek collects demographic and personal information for the purpose of ensuring the inclusion and safety of all participants, it helps us understand who is in our programs and is in alignment with results we need to report to our funders. We are committed and subscribed to the highest level of confidentiality and to protecting the privacy and personal information of all participants. All data that is reported is aggregated and will not identify individual participants or families. We appreciate your willingness to complete this section.Participant identifies as a person: First Nations Metis Inuit Black 2SLGBTQIA+ Visible Minority/Person of Color White (Caucasian) Person With Disability Prefer Not To Answer None of the Above (Please specify below) Specify Identity Here PARTICIPANT HEALTH INFORMATIONPHIN Number (9 Digits)*Medical Registration Number (6 Digits)*Does participant have a Birth Certificate?* Yes No Does participant have a Social Insurance Number (SIN)?* Yes No Participant has the following special medical needs:* Allergies (Please specify in the description box) Carries an inhaler (Participant can self administer) Carries and EpiPen (Participant can self administer) A Medical Alert Bracelet Dietary Accommodations (Please specify in the description box) Additional Health Concerns (Please specify in the description box) Has a disability None Please provide Career Trek Inc. with the following: Description and detail(s) of the condition(s); symptoms, or triggers (if applicable), management strategy, medication requirements, food, and dietary accommodations.*I would like to request an accommodation consultation to discuss specific needs, support options, or adjustments for program participation. Yes No If yes, a Career Trek staff will contact you. CONSENT FOR PHOTOGRAPH FOR ADMINISTRATIVE PURPOSESCareer Trek takes pictures of participants at programming for administrative and promotional reasons. The administrative reasons for taking pictures include health, safety, and identification.I understand that pictures may be taken and used for administrative reasons, and I am providing consent for the participants to be photographed. Yes No CONSENT FOR PROMOTIONAL PHOTO CAPTUREThe promotional reasons for taking pictures of participants include raising awareness of Career Trek through advertising, marketing, and fundraising. This includes but is not limited to news stories, paid advertising, proposals, reports to funders, and print materials.I understand that photographs may be taken for promotional purposes, and I am providing consent for the participant to be photographed. Yes No Career Trek publishes a monthly newsletter and issues occasional electronic information updates. Topics can include information on program changes, of special events, organizational updates, employment information, volunteer opportunities, contests, and more. You can unsubscribe at any time. Yes, keep me in the loop No, I’m not interested Acknowledgment of Risks & WaiversI understand that accidents and injuries can happen as part of the programming and activities being provided by Career Trek. I hereby release and waive all rights to any claim or action against Career Trek arising from injury, loss, or damage to the participant while participating in the program.* Agree I acknowledge that it is the participant’s responsibility to ensure their safety before and after programming by following the rules and expectations set out by Career Trek and its partners. I hereby release Career Trek from all liability for any harm or injury to the participant however the harm or injury is caused.* Agree I hereby authorize Career Trek to seek emergency medical assistance on the participant’s behalf and to contact the emergency contacts if I cannot be reached.* Agree I understand that any alternate persons picking up the participant(s) needs to provide picture ID and must be 18 years or older. I understand that I must inform Career Trek staff in advance by telephone/email of the arrangements, or the participant will not be released.* Agree I give consent for the participant to participate in any offsite activity during the program. I understand that transportation to and from these activities will be provided by the First Student Bus Lines which will be under the supervision of Career Trek staff.* Agree In the case that any in-person programming will occur during the program, I understand that injuries can arise by accident from the very nature of Career Trek Inc.’s activities, and I hereby release and waive all rights to any claim or action against Career Trek Inc. arising from injury, loss, or damage to the participant named in this application. I hereby authorize Career Trek Inc. to seek emergency medical assistance for the participant named in this application if the parents/guardians or emergency contact cannot be contacted. Career Trek Inc. photographs/interviews participants for administrative and promotional reasons. The administrative reasons for photographing participants include health, safety, and identification. I understand that photographs of the participant named in this application may be taken and used for the administration reasons noted above. The promotional reasons for photographing participants include: raising awareness of Career Trek through advertising and marketing activities (news stories, paid advertising and print materials). I have read, understand, and agree to the above.* Yes No PARENT/GUARDIAN INFORMATIONParent/Guardian Name* First Name Last Name Relation to Participant* Mother Father Guardian Primary Contact:* Yes No Primary Phone*Primary Phone Type*MobileHomeWorkOtherEmail* Address (if different than Participant) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Would you like to add an additional Parent/Guardian? Yes No Parent/Guardian Name First Name Last Name Relation to Participant Mother Father Guardian Secondary PhoneSecondary Phone TypeMobileHomeWorkOtherEmail Preferred method of communication for this parent/guardian* Cell phone Home Phone Email Address (if different than Participant) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code EMERGENCY CONTACT INFORMATIONCareer Trek Inc. collects personal information for the purposes of communicating with parents/guardians, ensuring participant safety, and tracking program outcomes. We are committed to protecting your personal information.Emergency Contact - other than parents/guardians* First Name Last Name Primary Phone*Relationship to Participant:* PARTICIPANT SIGN-IN & SIGN OUTAt the end of a program day/session* Listed parent/guardian will pick up participant(s) My child(ren) can leave on their own after the program session My child(ren) will need transportation provided through Career Trek (if available) My child(ren) can be picked up/dropped off by the listed individuals below. Listed individuals listed MUST PROVIDE VALID PHOTO IDENTIFICATION to a Career Trek staffPARTICIPANT & PARENT/GUARDIAN SIGNATURESParent/Guardian Name* First Last Date* Parent Signature* Yes, I understand and agree to the conditions listed above. Participant Name* First Last Date* In a few sentences, share why you wish to be part of the Junior Staff Mentorship Project.*Tell Us How You Heard About Career Trek Word of Mouth Social Media School/Educator Flyer/Poster Internet Search Advertisement
