2020 PSAC ONTARIO RACIALLY VISIBLE MEMBERS CONFERENCE

DELEGATE/OBSERVER STATUS *

To ensure that the Conference responds to the needs of our members, please complete all sections

I identify as Racially Visible

Name *

First and Last Name

PSAC ID # *

PSAC Membership #

Home Address *

City or Town *

Postal Code *

A1A 2B3

Component/Directly Chartered Local/Separate Employer *

Local #

Home Phone # *

(123) 456-7890

Cell Phone # *

(123) 456-7890

Personal email address *

Do not provide any Employer email addresses

Self-identification

Woman

Member with disabilities

Gay, lesbian, bisexual or transgendered member

Other...

Self-identification Other...

Self-identification - Indigenous/Aboriginal Worker

First Nation

Métis

Inuit

Other...

Self-identification - Indigenous/Aboriginal Worker Other...

Emergency Contact *

Please provide contact name and telephone #

SECTION #2: I am applying to the 2020 PSAC Ontario Racially Visible Members Conference, as a: *

Delegate

Observer

NOTE: Observer Status *

If you are not selected as a Delegate to the conference, do you want to be considered as an Observer?

Yes

No

ACKNOWLEDGMENT: Observer *

Yes

By checking the box above, observers acknowledge that they are responsible for securing their own travel and for covering all costs associated with their participation in the Conference. Observers will also be responsible to arrange for any childcare or accommodation needs directly with the hotel.

SECTION #3: Part A:

PARTICIPANT QUESTIONNAIRE

Question #1 *

What PSAC Conference have you attended?

Question #2 *

What Component Conference have you attended?

Question #3 *

I am a member of PSAC Regional/Component Human Rights or Women's or Pride or Aboriginal or Racially Visible or Persons with Disabilities Committee(s)

Yes

No

Question #4 *

Have you recently attended a PSAC or Component educational course?

Yes

No

PSAC EDUCATION COURSES *

Please list PSAC/Component Education courses you have attended (both weekend and in-residence)

KNOWLEDGE & EXPERIENCE *

How will the knowledge and experience you gain at the conference lead to Union action in your workplace, your local, region, component or your community? (150 words or less)

Community Activism *

Are you active in your community on Equity issues? Specify

SECTION #4: TRAVEL, HOTEL, CHILDCARE & ACCESSIBILITY REQUIREMENTS *

Do you have any dietary requirements or any allergies that we should be aware of?

Yes

No

TRAVEL *

Tell us how you're getting here. Participants are expected to travel by the most direct, economical means and all travel must be pre-approved with the conference administrator prior to attending

LOSS of SALARY Required: *

Please identify if you will require loss of salary for travel on Thursday, February 8, 2020. In most cases, a half day will be needed for travel. If you require Loss of Salary for Friday, Saturday, and/or Sunday, please indicate below, (for budget tracking purposes) Classification/Step or Hourly Wage, Number of Hours of Salary Required, Which days do you require loss of salary

HOTEL ACCOMMODATIONS *

I require specific accommodation for my disability in my hotel room

Other...we will follow up for additional information

HOTEL ACCOMMODATIONS Other...we will follow up for additional information

ON-SITE CHILDCARE FOR DELEGATES *

Do you require on-site childcare? *We will follow-up for additional information

Yes

No

The PSAC Accommodation Policy for delegates at PSAC Conferences strives to ensure that conferences are barrier-free for delegates with disabilities. Once selected, members may be required to specify further their accommodation needs in order to facilitate their participation at this conference. A separate form will be sent to select delegates

MEMBERS with DISABILITIES *

I will be accompanied by a personal care attendant to assist me at the conference. Please specify:

I require documentation in alternative media. Please specify:

I require sound amplification

I require a sign language interpreter

I require an oral interpreter

I require that the PSAC arrange for a Reader (for a person with a visually-related disability) to assist me in order to fully participate at the conference

I will be using animal assistance (i.e. guide dog) at the conference

I require other accommodation. Please specify

Other...

MEMBERS with DISABILITIES Other...

DID YOU REMEMBER TO: *

Registration fees to be mailed

REMINDER:

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2020 PSAC ONTARIO RACIALLY VISIBLE MEMBERS CONFERENCE

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