* denotes required fields
Title: *
First Name: * 
Last Name: * 
List Designations (if any):
Occupation:
(Please choose the occupation that best describes your current role)		 *
 
Date of Birth (YYYY-MM-DD):
   *  
Home Address: *
City: * 
Province: * 
Postal Code: * 
Employer: *
Type of Business:
Company Address: *
City: * 
Province: * 
Postal: * 
Management Contact Name:
(Name, Phone Number)		 *
 
Do you have your employer’s
support for participating in
events during work hours?		 *
Work e-mail: * 
Home e-mail:
Preferred contact e-mail:
Work Phone: - - *
Home Phone: -
Cell Phone: -
Emergency Contact:
(Name, Phone, Cell)
Do you have access to
transportation (i.e. car)?		 *

Your Education Journey
High School Name: *  
Post Secondary Institution(s): *  
Your Career and Education Journey...
How did you get to where you are today?*
Briefly describe your current professional responsibilities...*
Unique Story... In your job?...In your education?…Inspiration?...Achievements?*

Presentation Experience
Have you done a presentation? *
If yes, how many have you done?
What is your comfort level in
delivering a presentation?		 *

Awards and Activities
Awards:
List activities that involve youth
(i.e. coaching, mentoring, etc.):		 * 

Commitment Level
Are you able to commit to four (4)
or more career events and
classroom presentations within
a school year (Sept – June)?		 *


Comments
What are your reasons for volunteering for this program?
What objectives do you hope to reach?*
What other things can you tell us about yourself? (i.e. characteristics, extra curricular activities, interests, etc.)