Apply NowOpening their eyes to a world of self-discovery, career options, and empowerment.Connect with UsPhone: (204) 944-1800 Fax: (204) 942-4912 Toll-free: 1-800-693-3864 [email protected]Apply Now Step 1 of 6 16% PARTICIPANT INFORMATIONHow did you hear about this opportunity?*Participant First Name* First Name Participant Last Name* Last Name Preferred namePreferred Pronouns (EG: She/Her/Hers; He/Him/His; They/Them/Theirs; Other)*In which region of Manitoba do you live?* Winnipeg The Pas (North) School (if applicable)GradeCommunity organization participant is applying through (if applicable)Primary Phone Number*Primary Phone Type*Mobile PhoneHomeWorkSecondary Phone NumberSecondary Phone Type*Mobile PhoneHomeWorkEmail* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Date of Birth* MM slash DD slash YYYY Age as of today's date*Participant identifies as a person:* with a disability of a visible minority group of Indigenous ancestry who is a Newcomer to Canada (settled in Canada within the last 5 years) with Refugee status prefer not to answer Does participant have a Social Insurance Number (SIN)?* Yes No SIN (xxx-xxx-xxx)*Career Trek can assist you with obtaining a SINCareer 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 PARTICIPANTS WITH INCOMPLETE APPLICATION FORMS WILL NOT BE ENROLLED IN THE PROGRAM. Child InformationChild's Name*Child's Date of Birth* MM slash DD slash YYYY Please indicate if your child has have any allergies or health conditions with the following: name and detail of the condition, symptoms of allergy, triggers of condition or allergy.Child's 9-digit Manitoba Health number*Child's 6-digit Medical Number*Would you like to enter information for a second child? Yes No Second Child Name*Second Child's Date of Birth* MM slash DD slash YYYY Please indicate if your child has any allergies or health conditions with the following: name and detail of the condition, symptoms of allergy, triggers of condition or allergy.Second child's 9-digit Manitoba Health number*Second child's 6-digit Health Number*Would you like to enter information for a third child? Yes No Third Child's Name*Third Child's Date of Birth* MM slash DD slash YYYY Please indicate if your child has have any allergies or health conditions with the following: name and detail of the condition, symptoms of allergy, triggers of condition or allergy.Child's 6-digit Medical Number*Child's 9-digit Manitoba Health number*Would you like to enter information for a fourth child? Yes No Fourth Child's Name*Fourth Child's Date of Birth* MM slash DD slash YYYY Please indicate if your child has have any allergies or health conditions with the following: name and detail of the condition, symptoms of allergy, triggers of condition or allergy.Child's 9-digit Manitoba Health number*Child's 6-digit Medical Number* PARENT/GUARDIAN INFORMATIONParent/Guardian Name* First Name Last Name Relation to Participant* Mother Father Guardian Primary Contact:* Yes No Primary Phone NumberPrimary Phone Type*MobileHomeWorkOtherSecondary Phone NumberSecondary 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 Primary Contact: Yes No Primary Phone*Primary Phone Type*MobileHomeWorkOtherSecondary PhoneSecondary 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 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 INFORMATIONPlease indicate if the participant has any of the following allergies or health conditions:* 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 Participant's 9-digit Manitoba Health number*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).Are you vaccinated?* Yes No Prefer not to answer Please be advised that unvaccinated individuals may not be able to participate in all programming activities due to the policies outlined by our partners. If you have any questions or concerns you wish to discuss with us, please contact Nickoya Jones (Program Manager, Youth Initiatives) at [email protected] 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). Acknowledgement* I have read and understand the above. I hereby authorize Career Trek Inc. and its designated partners to take, store, and use photographs/interviews of my participant for promotional purposes.* Yes No Name of Participant:*Please type your name in lieu of a signature. Parent or Guardian NameAcknowledgement* I have read and understand the above. Commitment Contract for ParticipantsIf you were to be selected to be part of the M-Power Program, we need to know that you would be committed and agree to what is expected of you as a participant of this program. By signing this contract you are agreeing to the rules and expectations of the M-Power Program. •I promise to respect all the rules, participants, staff members, and volunteers while part of the M-Power Program •I promise to attend (virtually or in person) to 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 the M-Power Program Name First Last Yes, I understand and agree to the conditions listed above. Date MM slash DD slash YYYY NumberUntitled
