Apply Now Opening their eyes to a world of self-discovery, career options, and empowerment. Connect with Us Phone: (204) 944-1800 Fax: (204) 942-4912 Toll-free: 1-800-693-3864 [email protected] Apply Now Step 1 of 5 20% PARTICIPANT INFORMATIONParticipant First Name* First Name Participant Last Name* Last Name Preferred name Gender Female Male Other Preferred Pronouns (EG he/him/his; she/her/hers; they/them/theirs) In which region of Manitoba do you live? Winnipeg and area West (Brandon) Other* Primary Phone Number*Primary Phone Type*Mobile PhoneHomeWorkSecondary Phone NumberSecondary Phone Type*Mobile PhoneHomeWorkEmail* Preferred method of communication* Cell phone Home Phone Email Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code School* Community organization participant is applying through (if applicable) Date of Birth* MM slash DD slash YYYY Participant identifies as a person: with a disability of a visible minority group of Indigenous ancestry that is a Newcomer to Canada (settled in Canada within the last five years) with Refugee status Does Participant have a Social Insurance Number?* Yes No Career Trek can assist you with obtaining a SIN.Does Participant have a birth certificate?* 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 PARENT/GUARDIAN INFORMATIONParent/Guardian Name* First Name Last Name Relation to Participant* Mother Father Guardian Primary Contact:* Yes No Primary PhonePrimary Phone Type*MobileHomeWorkOtherSecondary PhoneSecondary Phone Type*MobileHomeWorkOtherEmail* Preferred method of communication for 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 Would you like to add an additional parent/guardian? Yes No Parent/Guardian Name First Name Last Name Relation to Participant Mother Father Guardian Primary Contact: Yes No Primary Phone*Primary Phone Type*MobileHomeWorkOtherSecondary PhoneSecondary Phone Type*MobileHomeWorkOtherEmail* 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 Career 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. HEALTH INFORMATIONManitoba Health Number (6 digits)* Personal Health Number (9 digits)* My Participant has the following special medical needs:* Allergies Dietary concerns Asthma Carries an autoinjector (EpiPen) Carries an inhaler Wears a MedicAlert bracelet Has a disability Has additional medical conditions. Please specify below. None Please provide Career Trek Inc. with the following: name and detail of the condition, symptoms of allergy, triggers of condition or allergy, management strategy, dosage requirements (if medication is required).Emergency Contact - other than parents/guardians* First Name Last Name Primary Phone*Secondary Phone*Relationship to Participant:* ACKNOWLEDGMENT OF RISKS AND WAIVERSIn 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 I hereby authorize Career Trek Inc. and its designated partners to take, store, and use photographs/interviews of the participant for promotional purposes.* Yes No Name of Parent/Guardian:* Please type your name. This will be used in lieu of a signature. Commitment Contract for Participants and FamiliesParticipants If you are selected to be part of the Junior Staff Mentorship Program (JSMP), we need to know that you would be committed and agree to what is expected of you as a participant. By signing this contract you are agreeing to the rules and expectations of JSMP: •I promise to respect all the rules, participants, staff members, and volunteers while part of JSMP •I promise to attend every program day as long as I am not sick or have a family commitment that day •I promise to be responsible in informing Career Trek when I know that I am going to be absent •I understand that if I do not keep my promises, Career Trek can remove me from JSMPFAMILIES Career Trek has programming and initiatives designed to encourage the participant along their career development journey. Supportive family relationships play an important role in a child’s success and we need your commitment in making this a successful experience for them. By signing this contract, you are agreeing to the rules and expectations of the project, should the child be selected to be part of the Junior Staff Mentorship Program (JSMP) •Our family promises to ensure that our child attends every scheduled programming day •Our family promises to ensure that our child informs Career Trek when they cannot attend a programming day •Our family understands that if we do not keep our promises, Career Trek can remove our child from JSMP Name* First Last Date* MM slash DD slash YYYY * Yes, I understand and agree to the conditions listed above. In a few sentences, share why you wish to be part of the Junior Staff Mentorship Project.*Name* First Last Date* MM slash DD slash YYYY * Yes, I understand and agree to the conditions listed above. Please note: There is an enrollment fee of $25 which those selected to participate will be expected to pay either before or on the first day of programming (cash, cheque, and e-transfer options are all available)
