FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY (FOIP) STATEMENT
The collection of personal information on this form is authorized pursuant to section 33(c) of the Freedom of Information and Protection of Privacy Act (FOIP Act) and will be used for the purposes of assessing and making recommendations regarding your eligibility or suitability for attendance at the Speak Out Conference. If you are selected to attend, you are consenting to the publication of your name, city/town and a mutually agreed-to member profile statement through news releases, to publicize and promote the Conference and the Speak Out program. If you have any questions or inquiries regarding the collection and use of your personal information please contact Kelley Bessette, Speak Out – Student Engagement Initiative, 12th Floor, 44 Capital Boulevard, 10044 108 Street, Edmonton, AB, T5J 5E6, (780) 422-0390.

 
SPEAK OUT CONFERENCE APPLICATION
* Required fields
CONTACT INFORMATION
  First Name *
  Last Name *
  Gender * Male       Female
  Date of Birth *  /   /   (yyyy/mm/dd)
  Age *
  Address *
  City/Town *
  Postal Code *
  Phone Number (Home) * () -   -    Ext. 
  Phone Number (Cell) () -   - 
  Email *
  Are you a student right now? * Yes       No
  Do you have any special dietary concerns?   Yes       No  
  If yes, please provide as much detail as possible  
   
  Will you require special assistance to participate in the conference activities?   Yes       No  
  We will try our best to accommodate these requests. Please provide as much detail as possible  
   
PERSPECTIVES
  Based on your perspectives, background and experiences, what would you bring to the Conference? (check all that apply) *  
  Rural
North
Dropped out
Full-time employed
Métis
First Nations
Immigrant
Person with a disability
French Immersion
Urban
In school
Graduated
Part-time employed
Inuit
Visible Minority
English as a Second Language
Francophone
Other
 
 
  What do you feel are three key education issues for youth in Alberta?
(Please limit your answers to 25 words for each issue.) *		  
  Issue 1     
  Issue 2     
  Issue 3     
 
  If you have been involved with Speak Out previously, please check all that apply:  
  Website (www.speakout.alberta.ca)
Speak Out Forum
Speak Out Conference
Minister’s Student Advisory Council
 
GENERAL INFORMATION
  How did you hear about the Speak Out Conference? *  
  Online at www.speakout.alberta.ca
Speak Out Forum
From a friend
From a teacher
From a parent
From a poster
From the news
From an online ad
From a television ad
From a print ad (in a magazine, newspaper, etc.)
Other
 
 
  Would you like to receive more information on the Speak Out program through e-mail updates?
Yes            No		  
 
 

Please note that your application is not complete until the Parent/Guardian Consent form has been signed by your parent or guardian and received by the Speak Out Team. A confirmation e-mail will be sent upon receipt of your completed application.