ࡱ> [ ^ bjbj "Fjj3*lRRRRRRRf8<V4f2d " giiiiii$ :!R RR  R R g g|RRS  Zf|z WS0i!& !SffRRRR LEAD YOUR WAY! NATIONAL ABORIGINAL ROLE MODEL PROGRAM COMMUNITY VISIT REQUEST FORM Preferred Role Model:  FORMCHECKBOX  Alika LaFontaine  FORMCHECKBOX  Annie Novalinga  FORMCHECKBOX  Jenna Walker  FORMCHECKBOX  Amanda Bailey  FORMCHECKBOX  Ashley Paniyuk-Dean  FORMCHECKBOX  Jodie-Lynn Waddilove  FORMCHECKBOX  Jonathon Potskin  FORMCHECKBOX  Kipanik Eeegeesiak  FORMCHECKBOX  Tony Liske  FORMCHECKBOX  Nadine Gagn  FORMCHECKBOX  Michael Putulik  FORMCHECKBOX  Tyrone MacNeil Please note: Our 2004 National Spokesperson, Jordin Tootoo, is not available for community visits. ANCESTRY:  FORMCHECKBOX  First Nations  FORMCHECKBOX  Mtis  FORMCHECKBOX  Inuit  FORMCHECKBOX  Any available role model PARTICULAR AGE GROUP:  FORMCHECKBOX  13-17  FORMCHECKBOX  18-22  FORMCHECKBOX  23-30  FORMCHECKBOX  Any age PARTICULAR INTEREST/FIELD:  FORMCHECKBOX  Volunteer  FORMCHECKBOX  Excellent Student  FORMCHECKBOX  Traditional teachings  FORMCHECKBOX  Athlete  FORMCHECKBOX  Aboriginal Language (speaks/teaches)  FORMCHECKBOX  Healthy  FORMCHECKBOX  Helpful  FORMCHECKBOX  Creative  FORMCHECKBOX  Entrepreneur  FORMCHECKBOX  Funny  FORMCHECKBOX  Overcoming adversity  FORMCHECKBOX  Other: _____________________________ Completion of this form is a request only and DOES NOT guarantee a role model visit. Please type or print. Fill out completely. Please refer to community visit guidelines for more information. ORGANIZATION:  FORMCHECKBOX  School  FORMCHECKBOX  Community  FORMCHECKBOX  Charity  FORMCHECKBOX  Youth Group  FORMCHECKBOX  Support Address: _____________________________________________________________________ Town/City: __________________Province: __________ Postal code: ___________________ Telephone: ___________________________________ Fax: ____________________________ Contact name: ________________________________ Contact telephone: _______________ Event: ______________________________________________________________________ Event sponsor: ________________________________________________________________ Event day & date: ___________________________ Event time: ________________________ Length of event: _____________________________ (Forms received without a specific date will not be considered.) Event Location: _______________________________________________________________ On-site contact name: ____________________________________________________________ Event address: __________________________________________________________________ Event theme: ___________________________________________________________________ Event description (please be specific, i.e. theme): ______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Role model function at event: __________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Audience size: ____________________ Audience age-range: ___________________ Requested role model: 1. ________________________ 2. ______________________________ Recommended Attire: ____________________________________________________________ Will food and/or beverage/water be provided?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Directions to event location: ___________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Travel Information to Community: Bus:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Name of Bus Line: ______________________________________________________________ Days and times of arrivals: ____________________________________________________ Days and times of departures: ____________________________________________________ Rail:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Name of Rail Service: ____________________________________________________________ Days and times of arrivals: ____________________________________________________ Days and times of departures: ____________________________________________________ Road Access:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Main Road/Highway: __________________________________________________________ Alternative Route: __________________________________________________________ Air:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Name of Airline: _______________________________________________________________ Days and times of arrivals: ____________________________________________________ Days and times of departures: ____________________________________________________ Connector Flights required:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Connector travel required:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Type of travel: ____________________ Required Arrangements: __________________________________________________________ Best method of travel to your event (please describe): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Hotel/Accommodations Information at Community: Name of Hotel: _________________________________________________________________ Contact person (if applicable): _____________________________________________________ Telephone: _______________________________ Fax: _________________________________ Requesting: FULL coverage of expenses/travel/accommodation:  FORMCHECKBOX  Yes  FORMCHECKBOX  No PARTIAL coverage:  FORMCHECKBOX  Travel  FORMCHECKBOX  Expenses (Food, incidentals)  FORMCHECKBOX  Accommodations NO coverage: Community/organization will be responsible for all expenses, including travel/expenses/accommodations  FORMCHECKBOX  Yes  FORMCHECKBOX  No Please note: Media may be covering the event. The National Aboriginal Health Organization will monitor the media coverage of the event. Please note: Host organizers who receive a role model visit are required to provide a full report of the event to the National Aboriginal Role Model Program. This will be used for evaluating the program. For more information contact: National Aboriginal Role Model Program National Aboriginal Health Organization 220 Laurier Ave. W, Suite 1200 Ottawa, ON K1P 5Z9 Tel.: (613) 237-9462, ext. 548 Toll free: 1-877-602-4445, ext. 548 Fax: (613) 233-1853 E-mail:  HYPERLINK "mailto:leadyourway@naho.ca" leadyourway@naho.ca     PAGE  PAGE 3 9:WZnrs&'567NO]^_tujhUmH sH jUjUj UjUj$UjUj<UjȇUjTU5;CJaJCJ>*5\ jU:9:WXZqrN !(Ga{ p^p``$p^pa$$a$$a$3 ]   !,ae&-.<=>GHVWXabpqr{|j|UjUjUj UjUj8UjČU 5CJ\5CJCJ6CJ CJmH sH jPUj܋U jUmH sH :  !/01=>LMNtu     + jUjxUjUjUjUjUj4UjUjLUjؐUjdU5\ jUjU;{ t+ d e ) * : ;  i \  1 r s  !$a$ p^p`+ , : ; < c d ( ) 8 ; < J K L V W e f g r s  2 p r s !STASh{fguvw~jUjUjUj0UjUjHUjԕU 5CJ\CJ5\j`U jUDs hcTABC86)~56  #$%01?@AGHVWXdestu{|ABPQRXYghijCJUjCJUj,CJUjCJUjDCJUjКCJUj\CJUjCJUjtCJUjCJU jCJU;5\CJ7~%*\V,<mfklEelDEKLZ[\bcqrshiwxyjCJUj@CJUj̟CJUjXCJUjCJUjpCJU5\ 5CJ\jCJUjCJUCJ jCJU9 wx  4\{3 5  & F `^`` ^` ^`    1 2 3 4 6 7 9 : < = ? @ F G H J L M S T U V X ] ^ ʿ0JmHnHu0J j0JU jU0JCJjCJU 5CJ\CJ jCJUj(CJU"5 6 8 9 ; < > ? 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