Application Form
Sustainability Learning Series 2015
Please print all information; submit this form by email to
[email protected] in person to: Nicole Vaugeois, Building
250 Vancouver Island University, 900 Fifth Street, Nanaimo, BC V9R
5S5LEARNING SERIES
( Aboriginal Tourism - June 8-13th, 2015
PERSONAL INFORMATION
NAME
ADDRESS
CITYPROVINCEPOSTAL CODE
CountryStatePostal Code
DATE OF BIRTH:
_______/________/_______
DAY MONTH YEAREMAIL:HOME PHONE: ( ) -
CELL PHONE: ( ) -
MEDICAL NUMBER AND PROVINCE OF ISSUE
VIU STUDENT # (if appropriate)
YEARMAJOR
ORGANIZATION (if appropriate)
MAY WE RELEASE YOUR NAME AND CONTACT INFORMATION TO OTHER
PARTICIPANTS ( YES ( NO Unless there is a promotional reason for
this delete it and implement at the beginning of the tripEMERGENCY
CONTACT
NAME
PHONE NUMBER
( ) -RELATIONSHIP
TRAVEL PLANNING INFORMATION
LIST ANY ALLERGIES WE SHOULD BE AWARE OF
LIST ANY SPECIAL DIETARY REQUIREMENTS FOR ANY MEALS OR SNACKS
THAT MAY BE PROVIDED
LIST ANY PHYSICAL LIMITATIONS OR DISABILITIES WE SHOULD BE AWARE
OF
STUDENTS: IF APPLICABLE: NAME OF APPLICANT YOU WOULD LIKE TO
SHARE A ROOM WITH?
CANCELLATION POLICY Does a two week cancelation policy allow
enough time based upon committed reservation policies or does the
statement need to read four weeks? A minimum of 10 participants is
required to implement and deliver the Learning Series. If the
numbers do not warrant program delivery, three weeks prior to the
start date all registered participants will be refunded 100%. The
Aboriginal Tourism Planning Committee reserves the right to make
the final decision. REFUND POLICY
Deposit is non-refundable if a participants cancels three weeks
prior to program start.I AGREE TO THE ABOVE CANCELLATION AND REFUND
POLICY.THE INFORMATION ON THIS FORM IS COLLECTED UNDER THE
AUTHORITY OF THE COLLEGE AND INSTITUE ACT. THE USE OF THIS
INFORMATION WILL BE IN COMPLIANCE WITH THE FREEDOM OF INFORMATION
AND PROTECTION OF PRIVACY ACT. ANY QUESTIONS CONCERNING THE
COLLECTION AND USE OF THIS INFORMATION SHOULD BE DIRECTED TO Nicole
Vaugeois [email protected].
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SIGNATURE
DATE
