Fairlawn Avenue United Church Gibimishkaadimin Application Form - Fairlawn Avenue United Church

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Events
- News
  - Fairlawn Greetings!
Explore Spirituality
Experience Belonging
- Social
- Support
Embrace Action
Affirm
About Us

Gibimishkaadimin Online Application Form

Youth Information
Youth's name*
Youth's Email (if any)
Date of Birth*
Gender Identity*
Address*
Street Address Address Line 2 City Province Postal code
Youth's Cell Phone, if any
Please tell us the ethnic group that you identify with:*
If you are Indigenous, please tell us your nation/community / land claims settlement:
If you are First Nation, please tell us if you live on reserve or off reserve:
- On reserve
- Off reserve
What is your connection to The United Church of Canada, if any (50-100 words):
What is the name of your Congregation, if any
Please tell us why you, the youth applicant, would like to participate in Gibimishkaadimin (150-200 words):*
Parent/Guardian Information
Names of Parent(s)/Guardian(s):*
Email of 1st Parent/Guardian:*
Email of 2nd Parent/Guardian - if applicable:
Main Phone to reach Parent(s)/Guardian(s):*
Second Phone for Parent(s)/Guardian(s) - cell, work, etc., if applicable
Third Phone to reach Parent(s)/Guardian(s), if applicable
First Emergency Contact: (Name/Relationship/Phone/Email/Address)*
Second Emergency Contact, if applicable (Name/Relationship/Phone/Email/Address)
Any additional contact information in case of emergency:
Health Information
Health Card Number, Version Code and Province*
Our activities include canoeing, swimming, hiking, cooking out of doors and sleeping in tents. To enjoy the trip, you must be physically fit to do these activities. GENERAL HEALTH AND LEVEL OF FITNESS - Please rate your level of fitness.*
- 1 = little fitness
- 2 = some fitness
- 3 = average fitness
- 4 = good fitness
- 5 = excellent fitness
CANOEING ABILITY - Please rate your ability*
- 1 = no ability/experience
- 2 = some ability/experience
- 3 = average ability/experience
- 4 = good ability/experience
- 5 = excellent ability/experience
SWIMMING ABILITY - Please rate your ability*
- 1 = no ability/experience
- 2 = some ability/experience
- 3 = average ability/experience
- 4 = good ability/experience
- 5 = excellent ability/experience
HIKING ABILITY - Please rate your ability*
- 1 = no ability/experience
- 2 = some ability/experience
- 3 = average ability/experience
- 4 = good ability/experience
- 5 = excellent ability/experience
Food preferences: Are you vegetarian? vegan? Do you have dietary restrictions? food allergies?*
- Vegetarian
- Vegan
- Dietary restrictions (describe below)
- Food allergies (describe below)
- Other dietary needs (describe below)
- None of the above
Describe your food allergies or dietary needs, if any:
Do you have other allergies, or any physical, mental or health concerns:*
- Yes (describe below)
- No
Describe your allergies, physical, mental or health concerns, if any:
Are you bringing medications?*
- Yes (describe below)
- No
List the medications you are bringing, including the name of the drug, dosage and frequency:
Please bring medication in original bottles, with the label showing your name. Bring all medications in your carry-on luggage, if you are flying.
Doctor’s Name:*
Doctor’s Address and Phone Number:*
Youth Consent
Note: We can only accept applications where the Youth agrees to all of the policies below.
I, the youth applicant, understand that Gibimishkaadimin is a week-long wilderness canoe trip. I acknowledge that Gibimishkaadimin has a no alcohol and no recreational drugs policy that will be enforced.*
- Yes
- No
Parental/Guardian Consent for Gibimishkaadimin
Note: We can only accept applications where the Parent/Guardian gives consent to all of the permissions below.
(1) I, the parent/guardian, give permission for the above-named participant to attend Gibimishkaadimin and participate in all the activities in the program. (2) I, the parent/guardian, have disclosed all pertinent medical information including medications. I give permission to allow the named Family Doctor to give medical information should it be required. If I cannot be contacted, I permit the leaders of the program to use their judgement in determining the extent of immediate medical care as required and the possibility of using the emergency services of a hospital or clinic. (3) I, the parent/guardian, give permission for Gibimishkaadimin to choose where the participant named above stays enroute to the canoe trip and returning home. (4) I, the parent/guardian, understand that Gibimishkaadimin has a no alcohol and no recreational drugs policy for all participants while on the trip. If a Program staff has reasonable cause, I give my permission for a search of my youth’s belongings. I understand that Gibimishkaadimin and the Program Leaders have the right to dismiss a participant, who, in their opinion, has displayed unacceptable behaviour. (5) I, the parent/guardian, give permission for the participant named above to have their picture taken during the program and give Gibimishkaadimin permission to use the picture in promotional material including the Gibimishkaadimin website and Facebook page, The United Church of Canada print and electronic media, and related sites.*
- Yes
- No
Comments and Questions
Warning
When you click "Submit", make sure you see the "Thank you" screen. Otherwise, please scan the form to find the Error Message(s). Complete the form, and click "Submit" again.

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Welcome to Fairlawn Avenue United Church, where you will discover a church that lives out its faith in a way that is both dynamic and life affirming. With our vibrant services of worship with inspiring music under the direction of Eleanor Daley, our challenging and uplifting spirituality gatherings from our Ministers, our commitment to our affirm ministry, combined with our profound belief in speaking with and for the marginalized, through our Social Justice and Embrace Action ministries, Fairlawn is a congregation whose faith is put into action each and every week.

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28 Fairlawn Avenue Toronto, Ontario M5M 1S7
416-481-6848

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Land Acknowledgement. Fairlawn acknowledges the sacred land on which our church stands. It has been a site of human activity for 15,000 years. This land is the territory of the Huron-Wendat and Petun First Nations, the Seneca, and most recently, the Mississaugas of the Credit River. The territory was the subject of the Dish With One Spoon Wampum Belt Covenant, an agreement between the Iroquois Confederacy and Confederacy of the Ojibwe and allied nations to peaceably share and care for the resources around the Great Lakes. Today, the meeting place of Toronto is still home to many Indigenous people from across Turtle Island, and we are grateful to have the opportunity to work in the community, on this territory. We are also mindful of broken covenants and the need to strive to make right with all our relations. The original nations continue to cry out for justice. As treaty people, we commit to listen, learn, and work toward justice and reconciliation.

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