Regional convention 2023 – Registration form

Under the theme “PSAC-Quebec : Driving mobilization”, the 11th PSAC-Quebec Convention will be held in Trois-Rivières from Friday June 2 to Sunday June 4, 2023.

Here is the registration form. This form can be completed by a delegate, an alternate delegate or an observer.

Don’t forget ! You have until February 28th at 11:59 pm to register.

PERSONAL INFORMATION

Last name *

First name *

PSAC Membership ID *

Component or Directly Chartered Local *

Local or Branch *

Area *

• Bas-Saint-Laurent/Gaspésie/Îles-de-la-Madeleine/Côte-Nord
• Estrie/Bois-Francs
• Laval/Laurentides/Lanaudière/Abitibi-Témiscamingue
• Mauricie
• Montérégie
• Montréal
• Québec
• Saguenay/Lac-Saint-Jean/Chibougamau/Chapais

Personal email *

Cellphone *

Mailing address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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EMERGENCY CONTACT

Full name *

Relationship *

Phone number *

CONVENTION INFORMATION

I am registering as a: *

• Delegate
• Alternate delegate
• Observer

I am registering as a delegate or alternate delegate with the approval of:

Delegates and alternate delegates must obtain prior approval from the authorized representatives of the delegating body. Without this approval, the registration will be rejected by the Credentials Committee.

I am registering as a delegate or alternate delegate to represent: *

• my local or branch
• the Quebec Council
• my area council
• my regional Women's committee
• my regional Equity committee
• the National Aboriginal Peoples' Circle
• my regional Young Workers committee
• my Component as a national officer
• my Component as a member of the NBoD or full-time VP

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

• Yes
• No

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

• Yes
• No

I am a first-time delegate / observer: *

• Yes
• No

SELF-IDENTIFICATION

Your self-identification status will be used by the Equity committee and your contact information will be shared with PSAC-Quebec Equity candidates.

I identify with an equity and/or youth activist group:

• 2SLGBTQIA+
• Indigenous
• Women
• Racially Visible
• Person with a Disability
• Young activist (under 35)

I agree that PSAC-Quebec may use the information provided in the self-identification section for the purposes of the convention:

• Yes
• No

If you identify as a young activist, what is your year of birth?

ACCOMMODATION

I will need a hotel room *

• One bed
• Two beds
• No room needed

Preferences will be given based on availability.

I will require on-site family care: *

• Yes
• No

If yes, how many children and their ages?

ACCESSIBILITY REQUIREMENTS

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.

Do you have a disability or disabilities? *

• Yes
• No

You do not need to disclose your diagnosis.

If yes, what are the functional limitations and restrictions resulting from your disability(ies)?

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

Please indicate any other requirements to accommodate functional limitations and restrictions.

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

Submit