2023 Convention Delegate Registration

December 14, 2022December 14, 2022

Name *

First

Last

PSAC Membership ID *

Component or Directly Chartered Local *

Local / Branch *

Personal Email *

Alternate Email

Home Phone

Cell Phone

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

EMERGENCY CONTACT *

First

Last

Relationship *

Phone Number *

I will be attending the Orientation Session on Rules of Order? *

I would like to request a printed copy of convention materials *

Are you a first time delegate? *

Equity Group & Young Worker Identification Self ID *

I agree that PSAC Prairies may use the information provided in the Self-ID section for convention and administrative purposes.

If you identify as a Young Worker, what is your year of birth?

Your self-ID status will be used for equity committees and your contact information will be shared with candidates for Prairies Region Council equity positions.

Do not send me campaign material

Hotel Room Request

One bed
Two beds
No hotel room required

Do you require on-site Family Care? *

If yes, how many children and their ages?

ACCESSIBILITY REQUIREMENTS FORM - Do you have a disability or disabilities? *

The PSAC is committed to accessibility and therefore we ask that you complete this form if necessary so that the PSAC can ensure your full participation at PSAC events. The form is confidential and the information provided will not be disclosed except where necessary to respond to your request for accommodation.

If yes to the above question, what are the functional limitations and restrictions arising from your disability or disabilities? (you do not need to disclose your diagnosis)

Accessibility Requirements

I require that the PSAC arrange a personal care attendant to assist me in order for me to fully participate at the conference.
I require documentation in alternative media.
I require sound amplification.
I require a sign language interpreter.
I require that the PSAC arrange for a Reader to assist me in order for me to fully participate at the Conference.
I will be using animal assistance (i.e. guide dog) at the Conference.

Please list options for accommodating your functional limitations and restrictions in order to allow you to fully participate in the event.

Other comments: You may be required to provide relevant medical documentation that will assist us to respond to your request.

PSAC T-SHIRT *

Standard T-shirt
Women's cut T-shirt

T-shirts will be distributed to all registered delegates to wear for our action during convention. Please note that arms are exposed.

2023 Convention Delegate Registration

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