Gibimishkaadimin Application Form

Youth Information

Youth's name*

Email*

Date of Birth*

Gender Identity*

Address*

Street Address Address Line 2 City Province Postal code

Youth's Cell Phone, if any*

Please tell us the ethnic group that you identify with:*

If you are Indigenous, please tell us your nation/community / land claims settlement:

If you are First Nation, please tell us if you live on reserve or off reserve:

On reserve
Off reserve

What is your connection to The United Church of Canada, if any (50-100 words):

What is the name of your Congregation, if any

Please tell us why you, the youth applicant, would like to participate in Gibimishkaadimin (150-200 words):*

Parent/Guardian Information

Names of Parent(s)/Guardian(s):*

Email of 1st Parent/Guardian:*

Email of 2nd Parent/Guardian - if applicable:

Main Phone to reach Parent(s)/Guardian(s):*

Second Phone for Parent(s)/Guardian(s) - cell, work, etc., if applicable

Third Phone to reach Parent(s)/Guardian(s), if applicable

Specify the name(s) of the people that you authorize to pick up your Youth:

Specify the name(s) of the people that you DO NOT authorize to pick up your Youth:

First Emergency Contact: (Name/Relationship/Phone/Email/Address)*

Second Emergency Contact, if applicable (Name/Relationship/Phone/Email/Address)

Any additional contact information in case of emergency:

Health Information

Health Card Number, Version Code and Province*

Our activities include canoeing, portaging, swimming, hiking, cooking out of doors and sleeping in tents. To enjoy the trip, you must be physically fit to do these activities. GENERAL HEALTH AND LEVEL OF FITNESS - Please rate your level of fitness.*

1 = little fitness
2 = some fitness
3 = average fitness
4 = good fitness
5 = excellent fitness

CANOEING ABILITY - Please rate your ability*

1 = no ability/experience
2 = some ability/experience
3 = average ability/experience
4 = good ability/experience
5 = excellent ability/experience

SWIMMING ABILITY - Please rate your ability*

1 = no ability/experience
2 = some ability/experience
3 = average ability/experience
4 = good ability/experience
5 = excellent ability/experience

HIKING ABILITY - Please rate your ability*

1 = no ability/experience
2 = some ability/experience
3 = average ability/experience
4 = good ability/experience
5 = excellent ability/experience

Food preferences: Are you vegetarian? vegan? Do you have food allergies?*

Vegetarian
Vegan
Food allergies (describe below)
Other dietary needs (describe below)
None of the above

Describe your food allergies or dietary needs, if any:

Do you have other allergies, or any physical, mental or health concerns:*

Yes (describe below)
No

Describe your allergies, physical, mental or health concerns, if any:

Are you bringing medications?*

Yes (describe below)
No

List the medications you are bringing, if any:

Please bring medication in original bottles, with the label showing your name.

Doctor’s Name:*

Doctor’s Address and Phone Number:*

Youth Consent

Note: We can only accept applications where the Youth agrees to all of the policies below.

I, the youth applicant, understand that Gibimishkaadimin is a week-long wilderness canoe trip. I acknowledge that Gibimishkaadimin has a no smoking, no vaping, no alcohol and no street drugs policy that will be enforced.*

Yes
No

Parental/Guardian Consent for Gibimishkaadimin

Note: We can only accept applications where the Parent/Guardian gives consent to all of the permissions below.

(1) I, the parent/guardian, give permission for the above-named participant to attend Gibimishkaadimin and participate in all the activities in the program. (2) I, the parent/guardian, have disclosed all pertinent medical information including medications. I give permission to allow the named Family Doctor to give medical information should it be required. If I cannot be contacted, I permit the leaders of the program to use their judgement in determining the extent of immediate medical care as required and the possibility of using the emergency services of a hospital or clinic. (3) I, the parent/guardian, understand that Gibimishkaadimin has a no smoking, no vaping, no alcohol and no street drugs policy for all participants while on the trip. If a Program staff has reasonable cause, I give my permission for a search of my youth’s belongings. I understand that Gibimishkaadimin and the Program Leaders have the right to dismiss a participant, who, in their opinion, has displayed unacceptable behaviour. (4) I, the parent/guardian, give permission for the participant named above to have their picture taken during the program and give Gibimishkaadimin permission to use the picture in promotional material including the Gibimishkaadimin website and Facebook page, The United Church of Canada print and electronic media, and related sites.*

Yes
No

Comments and Questions

Complete the form by March 31.

Please get back to us asap to allow time for us to correspond with you or your parent/guardian before the trip. When you click "Submit", a copy of the completed online application form will be sent to the youth and to the parent(s)/guardian(s) for your records.

Warning

When you click "Submit", make sure you see the "Thank you" screen. Otherwise, please scan the form to find the Error Message(s). Complete the form, and click "Submit" again.

Address:	28 Fairlawn Avenue Toronto, Ontario M5M 1S7
Visit us:	- Location - Parking
Phone:	416-481-6848
Fax:	416-481-4109
Email:	churchoffice@ fairlawnavenueunited.ca
Web:	fairlawnchurch.ca

Gibimishkaadimin Application Form

Gibimishkaadimin Online Application Form

Youth Information

Parent/Guardian Information

Health Information

Youth Consent

Parental/Guardian Consent for Gibimishkaadimin

Comments and Questions

Complete the form by March 31.

Warning

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