Registration form for Waves of Resistance

Posted August 6th, 2008 by

All items designated by an asterix (*) are mandatory and must be filled out for this form to be completed.

After you've completed this form you view your previous submissions, make modifications, and resubmit your form.

Identification

Surname: *

First Name: *

Date of Birth: * (DD/MM/YY)

Organizational or Activist Affiliation (if any):

Mailing Address: *

City: *

Province: *

Postal Code: *

Home Phone : *

Phone (work):

Cell Phone:

Email: *

Spoken Language(s): *

English

French

Other

Important Information

Are you under 18?: *

Yes

If yes, please identify the woman accompanying you to the Gathering and fill out the release form and the health form for minors.

Her surname:

Her first name:

Her Address:

Her city and province::

Her postal code:

Her home phone number:

Her cell phone number:

Her email:

Will you need daycare during the gathering?: *

Yes

If so, please fill out the health form for your child or children.

If so, how many children?:

Do you have a disability which may affect your participation at the Gathering?: *

Yes

Please explain::

Will someone be accompanying you?:

Yes

If so, please provide their name and contact information below.

Their surname:

Their first name:

Their phone number:

Their email:

How can we help?:

Travel

The Gathering will be held at the Université du Québec à Montréal (UQÀM), located at:
405, rue Sainte-Catherine Est
(514) 987-3000

Do you know how you will cover your travel costs?: *

Yes

If no, you may be able to obtain some travel support here.

Will you be travelling in a group?: *

Yes

If so, please complete the section below.

Name or provenance of the group:

Name of the person in charge:

Email of the person in charge:

Do you need assistance to get to the Gathering?: *

Yes

If so, please explain:

Itinerary

Date of arrival in Montreal: (MM/DD/YY)

Time of arrival in Montreal: (HH(0-23):MM)

Date of departure from Montreal: (MM/DD/YY)

Time of departure from Montreal: (HH(0-23):MM)

Accomodations

As much as possible the Organizing Committee would like to offer free accommodations for everyone. Please check the sections that correspond to your needs. We recommend you visit our page on accommodations to answer any further questions you may have.

I will find a place to stay in Montreal by myself:

Yes

If so, please check out "Affordable hostels in Montreal" for information on cheap accommodations.

I will be with a group and I want to stay with my group at the gymnasium reserved for the Gathering:

Yes

If so, please plan to bring a mattress and a sleeping bag.

Name or provenance of the group I will stay with:

Name of the person in charge of the group I will stay with:

Email of the person in charge of the group I will stay with:

I won't be with a group but I want to stay at the gymnasium:

Yes

Is so, please plan to bring a mattress and sleeping bag.

I have specific needs and cannot be staying at the gymnasium. I need assistance to find accomodations:

Yes

If so, please explain:

Thematic Workshop Preferences

Please indicate the THREE subjects you are interested in by order of preference (this list is an indication, and doesn’t represent the definitive program).

Workshops #1:

Workshops #2:

Workshops #3:

Would you be interested in volunteering as facilitator workshops or activities already scheduled for the Gathering?: *

Yes

If so, we will contact you shortly.

Registration Fees

The registration fee is $1 for every $1000 of gross annual income.
For women younger than 18, the fee is $5.
IMPORTANT: No woman will be refused registration for financial reasons.

Woman under the age of 18

I am under 18 and will pay $5: *

Yes

Woman aged 18 or over

$1 for every $1000 of gross annual income

The following amounts for family obligations may be deducted from gross income:
>With spouse (male or female): $2500 per dependant
>Without spouse: $5000 per dependant

My gross income minus family obligations is:

My registration fee is:

Gross income divided by 1000 times $1 = ?

If you need any help calculating your registration fee, click here.

Woman who cannot provide the requested fee

I cannot make any contribution:

Yes

I can provide a contribution of: $

Voluntary contribution to the Participants’ Travel Fund

To help cover travel expenses to allow one or more low-income young woman to attend the Gathering

I would like to add to my registration fee the following amount: : $

TOTAL REGISTRATION FEE AND VOLUNTARY CONTRIBUTION: * $

Payment

I will pay my registration fee by:

Postal Order

Cheque (Please label the cheque to "Federation des femmes du Quebec")

On site

Payments by mail must be sent to :
Fédération des femmes du Québec
a/s Toujours RebELLEs / Waves of Resistance
110 rue Sainte-Thérèse, bureau 309
Montréal, Qc
H2Y 1E6

Reminder

I am younger than 18 years old:

Yes

If you are younger than 18 you must download the release form as well as the health form for minors and you must be accompanied by a woman over the age of 18. These forms must be filled-out and signed by the participant and parent or person in charge, and faxed to 514-876-0162 or scanned and emailed to mobilisation@rebelles2008.org.

I will need child care services:

Yes

Participants who have children and would like to utilize our childcare services during the event must download the health form for your child. This form must be filled-out and sent by fax to 514-876-0162 or scanned and sent by email to mobilisation@rebelles2008.org.

I would like to apply to the Participant's travel fund:

Yes

Participants who would like to apply for to the Participants’ Travel Fund must download the Participants’ Travel Fund form. This form can be filled-out directly on your computer and sent to mobilisation@rebelles2008.org, or it can be printed and filled-out by hand to be sent by fax to 514-876-0162 or scanned and then sent by email to the same address.

Socio-Economic Background (Optional)

Questions:

Are you a student?

Are you from a cultural community and/or visible minority?

Do you come from a rural area?

Are you a parent or person in charge of a child?

Are you from a First Nations/Inuit/Métis community?

Are you an immigrant, migrant or refugee?

Do you identify as LGBTTQQ? (Lesbian, Gay, Bisexual, Trans, Two-spirits, Queer, Questioning)

Are you economically disadvantaged?

Commentaires

Confirmation of Registration

Once we have submitted a form, will we get confirmation of registration?

Thanks in advance!

| Fri, 09/26/2008 - 18:32

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Registration form for Waves of Resistance

Commentaires

Confirmation of Registration

confirmation

your form

new form.

Langues

info

Nouveaux thèmes de forum

Nouveaux commentaires

Ouverture de session d'utilisateur

Qui est en ligne

Registration form for Waves of Resistance

Commentaires

Confirmation of Registration

confirmation

your form

new form.

Langues

info

Nouveaux thèmes de forum

Nouveaux commentaires

Ouverture de session d'utilisateur

Rebelles circulaire/newsletter

Qui est en ligne