Program Application Form Parent/Guardian Information First Name * Last Name * Relationship to the Applicant —Please choose an option—FatherMotherGuardianOther Home Address * Phone Number * Email Address * Preferred Contact Method —Please choose an option—PhoneEmailRegular Mail Have you attended any SIA programs? —Please choose an option—English Language ProgramsEmployment ProgramsIntercultural ProgramsNone Country of Origin * Immigration Status —Please choose an option—Permanent Resident (SINP)Permanent Resident (Family Class)Permanent Resident (Express Entry)Permanent Resident (Economic Immigrant)Refugee (GAR)Refugee (PSR) Permanent Resident (UCI) Number * Are you currently enrolled in any SIA programs? —Please choose an option—YesNo If yes, please specify which programs: Are you currently employed? —Please choose an option—YesNo If yes, please specify your place of employment: Emergency contact phone number at your workplace (include extension if applicable): Program Choice * ConnectED Pathways Program How did you hear about this program? * —Please choose an option—Social Media (Facebook, LinkedIn, Instagram, Twitter)Internet Search (Google, Bing, Yahoo)Referral Agency (NAARS, IWS, LARC)Community OrganizationSIA StaffFamily or FriendsMedia (News)Advertising (Poster or Brochure) Would you like to be referred to a Francophone service provider to learn more about programs available in French? Yes, please refer meNo, not at this timeI am already connected with a Francophone service provider Are you able to transport your child? —Please choose an option—Own VehiclePublic TransportationNo Parent/Guardian Consent I consent to the below child (or children) to participate in the Pathways program through the Saskatchewan Intercultural Association. I consent to the sharing of my child’s information with SIA program funders and I understand that my child’s information will not be shared with any unauthorized third party, and all information gathered will be kept confidential. Date Parent/ Guardian Signature Applicant (Child’s) Information How many kids are you signing up? 12345678 Child Information - 1 First Name* Last Name* Preferred Name Date of Birth* Grade* —Please choose an option—K123456789101112 Gender—Please choose an option—BoyGirlOther Age—Please choose an option—6-89-1213-18 Date of Arrival in Canada Country of Birth Immigration Status —Please choose an option—Permanent Resident (SINP)Permanent Resident (Family Class)Permanent Resident (Express Entry)Permanent Resident (Economic Immigrant)Refugee (GAR)Refugee (PSR) Permanent Resident (UCI) Number* What school does your child attend?* Does your child have any allergies?* Dietary Restrictions Has your child attended the ConnectED program before? If yes, when?* Child Information - 2 First Name* Last Name* Preferred Name Date of Birth* Grade* —Please choose an option—K123456789101112 Gender—Please choose an option—BoyGirlOther Age—Please choose an option—6-89-1213-18 Date of Arrival in Canada Country of Birth Immigration Status —Please choose an option—Permanent Resident (SINP)Permanent Resident (Family Class)Permanent Resident (Express Entry)Permanent Resident (Economic Immigrant)Refugee (GAR)Refugee (PSR) Permanent Resident (UCI) Number* What school does your child attend?* Does your child have any allergies?* Dietary Restrictions Has your child attended the ConnectED program before? If yes, when?* Child Information - 3 First Name* Last Name* Preferred Name Date of Birth* Grade* —Please choose an option—K123456789101112 Gender—Please choose an option—BoyGirlOther Age—Please choose an option—6-89-1213-18 Date of Arrival in Canada Country of Birth Immigration Status —Please choose an option—Permanent Resident (SINP)Permanent Resident (Family Class)Permanent Resident (Express Entry)Permanent Resident (Economic Immigrant)Refugee (GAR)Refugee (PSR) Permanent Resident (UCI) Number* What school does your child attend?* Does your child have any allergies?* Dietary Restrictions Has your child attended the ConnectED program before? If yes, when?* Child Information - 4 First Name* Last Name* Preferred Name Date of Birth* Grade* —Please choose an option—K123456789101112 Gender—Please choose an option—BoyGirlOther Age—Please choose an option—6-89-1213-18 Date of Arrival in Canada Country of Birth Immigration Status —Please choose an option—Permanent Resident (SINP)Permanent Resident (Family Class)Permanent Resident (Express Entry)Permanent Resident (Economic Immigrant)Refugee (GAR)Refugee (PSR) Permanent Resident (UCI) Number* What school does your child attend?* Does your child have any allergies?* Dietary Restrictions Has your child attended the ConnectED program before? If yes, when?* Child Information - 5 First Name* Last Name* Preferred Name Date of Birth* Grade* —Please choose an option—K123456789101112 Gender—Please choose an option—BoyGirlOther Age—Please choose an option—6-89-1213-18 Date of Arrival in Canada Country of Birth Immigration Status —Please choose an option—Permanent Resident (SINP)Permanent Resident (Family Class)Permanent Resident (Express Entry)Permanent Resident (Economic Immigrant)Refugee (GAR)Refugee (PSR) Permanent Resident (UCI) Number* What school does your child attend?* Does your child have any allergies?* Dietary Restrictions Has your child attended the ConnectED program before? If yes, when?* Child Information - 6 First Name* Last Name* Preferred Name Date of Birth* Grade* —Please choose an option—K123456789101112 Gender—Please choose an option—BoyGirlOther Age—Please choose an option—6-89-1213-18 Date of Arrival in Canada Country of Birth Immigration Status —Please choose an option—Permanent Resident (SINP)Permanent Resident (Family Class)Permanent Resident (Express Entry)Permanent Resident (Economic Immigrant)Refugee (GAR)Refugee (PSR) Permanent Resident (UCI) Number* What school does your child attend?* Does your child have any allergies?* Dietary Restrictions Has your child attended the ConnectED program before? If yes, when?* Child Information - 7 First Name* Last Name* Preferred Name Date of Birth* Grade* —Please choose an option—K123456789101112 Gender—Please choose an option—BoyGirlOther Age—Please choose an option—6-89-1213-18 Date of Arrival in Canada Country of Birth Immigration Status —Please choose an option—Permanent Resident (SINP)Permanent Resident (Family Class)Permanent Resident (Express Entry)Permanent Resident (Economic Immigrant)Refugee (GAR)Refugee (PSR) Permanent Resident (UCI) Number* What school does your child attend?* Does your child have any allergies?* Dietary Restrictions Has your child attended the ConnectED program before? If yes, when?* Child Information - 8 First Name* Last Name* Preferred Name Date of Birth* Grade* —Please choose an option—K123456789101112 Gender—Please choose an option—BoyGirlOther Age—Please choose an option—6-89-1213-18 Date of Arrival in Canada Country of Birth Immigration Status —Please choose an option—Permanent Resident (SINP)Permanent Resident (Family Class)Permanent Resident (Express Entry)Permanent Resident (Economic Immigrant)Refugee (GAR)Refugee (PSR) Permanent Resident (UCI) Number* What school does your child attend?* Does your child have any allergies?* Dietary Restrictions Has your child attended the ConnectED program before? If yes, when?* Information Release Waiver: Consent to sharing personal information within SIA I consent to the Saskatchewan Intercultural Association to obtain, use, and release my personal information to any person or agency as may be necessary to support my learning and/or establish eligibility for my participation within other Saskatchewan Intercultural Association programs.YesNo Media Release Waiver: Consent to collect, use, and release media or comments I hereby grant the Saskatchewan Intercultural Association (SIA) permission to use photographs, video recordings, and any recorded comments made by me while participating in SIA programming. These materials may be utilized in various promotional platforms including, but not limited to, the SIA website, print media, and digital media. The sole purpose of using these materials is to promote SIA programming. Additionally, the media may be shared with community partners to highlight collaborative efforts.YesNo Travel Liability and Assumption of Responsibility Waiver Assumption of Risks: I understand that as a participant of Saskatchewan Intercultural Association’s Youth programs, the program will occasionally go on field trips to various locations. As such, I recognize that I may be exposed to risks to my person during periods of transportation or at offsite premises while participating in field trip activities. I freely and voluntarily accept and assume all risks, dangers and hazards. Accordingly, I understand that despite its efforts, the Saskatchewan Intercultural Association may not be able to ensure my complete safety at all times. Assumption of Responsibility: I understand that it is my responsibility to abide by all applicable Saskatchewan Intercultural Association policies and the policies of the host location. More particularly, I understand that the Saskatchewan Intercultural Association does not carry accident or injury insurance for my benefit and also that there may be certain matters for which I could be held at fault personally if my activities or conduct fall short of what would be considered a reasonable standard for an individual. In these cases, I agree to be accountable in all respects for my own actions and not to ask the Saskatchewan Intercultural Association or its employees to accept the consequences thereof; further, I agree to be responsible for any claims made against the Saskatchewan Intercultural Association in relation to such actions. I acknowledge that I have been advised by the Saskatchewan Intercultural Association of such risks and dangers as well as the need to act in a responsible manner at all times. My signature below is given freely in order to indicate my understanding of the acceptance of these realities and in consideration for being permitted by the Saskatchewan Intercultural Association to participate in the above-mentioned program. By signing this legal document, you give up certain legal rights, including the right to sue.YesNo Email Release Waiver: Consent to electronic communications I give consent to the Saskatchewan Intercultural Association to use my email address to contact me about SIA-related programs, services, and events. Examples of communications would be program information, registration deadlines, upcoming events and classes, and SIA news. I understand that I can opt-out and unsubscribe at any time.YesNo Subscribe to receive email communications from SIA about programs, events and announcements YesNo Δ
