Registration Form - Ontario First Nations HIV Education Circle Youth Peer Training
November 3-5, 2026 - London, ON
Name (Please include your full name as it appears on your Identification) ** especially important for those of you that will be flying
First Name
Middle Name
Last Name
Name as you would like it to appear on badge/certificate
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
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2016
2015
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2012
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Year
First Nation
Address
Street Address
Street Address Line 2
City
State / Province
Postal Code
E-mail
example@example.com
Mobile Number
Format: (000) 000-0000.
Travel Information
Note** - All delegates should travel with valid and up-to-date identification (e.g. status card, drivers license, health card, passport etc.); Also, please leave yourself enough time to travel comfortably. Those driving should take their time as snow may be expected on your route. Those flying must keep in mind that you need to be at airport no later than (1.5 hours prior to departure), if you are late you will not be able to board the flight.
Mode of Transportation
Driving
Flying
Location of Departure (November 2, 2026)
Location of Arrival (November 6, 2026)
ADDITIONAL INFORMATION - MEDICAL/ALLERGIES/DIETARY/EMERGENCY CONTACT
Note** - If a delegate has a specific medical concern and/or allergy, please identify this within the form so we are able to ensure that specific needs/requirements are accomodated. Any delegate with a medical/allergy concern much travel with appropriate medication(s).
Medical Concerns
Allergy Concerns
Dietary Concerns
Emergency Contact Information
Name & Relationship to delegate
Cellphone/Work Phone
Email
State / Province
Postal / Zip Code
CONSENT TO PHOTOGRAPHY/VIDEOGRAPHY/RELEASE OF IMAGE
There may be photographs and/or video footage taken throughout the duration of our Ontario First Nations HIV Education Circle Youth Peer Training. As such, we must obtain consent from all participants over the age of 18 and/or the parents/legal guardians of delegates under the age of 18 years in order to release and/or reproduce their image. This form allows us, the organizers, to utilize photos/videos taken during the event in the development of future publications/promotions/. Please sign this portion (if in agreement); to consent to the use of image, voice and/or other captions/depictions of me; being shared an/or used for the production of materials, promotion, publications etc. understanding that the promotions/publications/materials etc. may be shared widely.
Please check the following statement that applies
I am over the age of 18 and I consent to the use of audio/visual materials containing my image,voice and/or likeness
I am the parent and/or guardian of delegate and hereby affirm their/my consent to the use of audio and/or visual materials containing their image, voice and/or likeness
Signature of Delegate
*
Submit
Submit
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