TUXIS Parliament of Alberta

Nomination Form 92nd Annual Parliament December 26-31, 2011 Name: _______________________________________________________ M or F (circle one please) Date of Birth: (dd/mm/yy) _______________ Mailing Address: ____________________________ Phone #1: (____) _________________ E-mail: __________________________________________________ City: __________________________ Phone #2: (____) _________________ City: __________________________ Postal Code: ___________

Personal Information

Permanent Address (if different from above) ____________________________ Postal Code: ____________ Phone : (____) _________________

Alberta Health Care # _____________________________ Special Dietary Requirements: ____________________________ _____________________________________________________________________________________________________ Notable Medical Conditions: : _____________________________________________________________________________ Please attach extra information that would be needed in case of an emergent incident linked to a pre-existing medical condition during the time of Parliament. Emergency Contact Name: _________________________ Phone : (____) _________________

Other Information we should know: ________________________________________________________________________ Ideally, special requests should be submitted as early as possible. This Section is for statistical purposes only. You will not be evaluated on information provided in this section. Religious affiliation (if none, leave blank) _________________________ Have you attended a TUXIS Parliament of Alberta Session before? YES NO

General Information

If YES, which session(s)? ____________________________________________ Have you attended other TUXIS Parliament of Alberta events? Have you attended other Youth Parliaments before? YES NO YES NO

How did you find out about TUXIS Parliament of Alberta ? (i.e. Through church, family member, friends, teacher, internet, etc.) _________________________________________________________________________________________________ New Members note: If you are attending this session as a result of be recruited by a sitting member, please let us know who that member is: ________________________________________ If the Nominee has not reached his or her 18th birthday on or before December 25, 2011 the following must be completed by the Nominee's legal guardian.

Guardian Consent

I am aware that ______________________ will attend the 92 nd TUXIS Parliament of Alberta, December 26 th -31st, 2011, in
Nominees name

Edmonton, Alberta, and hereby give my consent. Guardian's Name :_________________________________

Printed Please

Relationship to Nominee: _________________________ Guardian's Signature: ____________________________ Date:______________

Transportation Release of Information

Parliament will arrange and coordinate transportation to the 92md Session for those Parliamentarians who live outside of the Edmonton Area either by public or private means of transportation. For those who provide their own transportation from outside of the city, mileage will be paid based on the number of active Parliamentarians in the members vehicle. Please check one of the following: ______ I will be in the Edmonton area already and have no transportation needs this Session. ______ I will need transportation to and from this address; ____________________________________________________ ______ I will be travelling from _____________________ to Edmonton and I have room for _______ riders in my vehicle. Please sign the following waiver (If Under 18 please have Guardian Sign): TUXIS Parliament of Alberta values the privacy of its members and their families and takes great care to protect the information entrusted to us. TUXIS Parliament of Alberta will never use personal information for any purpose for which your permission has not been given. I consent to the collection and use of information as outlined above. TUXIS Parliament of Alberta will use limited personal information during its regular operations, which include: Photos or videos that are used in electronic or print news media; Members names, photos, addresses, phone numbers and email addresses used in the Members Handbook given exclusively to members at the completion of Session to help the membership stay in touch; Members names and photos used in TUXIS Parliament of Alberta publications delivered to other members and the general public; and Other activities exclusively within the community of TUXIS Parliament of Alberta members. Name: Date: Signature: _____

Fees and Deadlines

The costs of the Parliament are covered partially by donation to the TUXIS Parliament Alumni Society, and partially by the Member's Registration Fee. These fees will be pooled and will pay for meals, accommodations, and travel to and from the event. Many Members choose to approach churches, community clubs and service groups, or local businesses in their communities to assist in funding for these Member's Fees. Early Bird Registration $200.00 per person Deadline November 15 Regular Registrations will be $250.00 per person. Returning Members are eligible to receive $25.00 per new member recruited

Nominations will generally be accepted in order of receipt, but some allocations may be made. Nominations shall be cut off on December 10, 2011. After this time a late registration fee may apply, please contact the Chief Returning Officer.

Contacts for Information

Where to Go for More Information?

You may contact the Chief Returning Officer: Benjamyn McKay (780) 498-0335 tuxiscro@gmail.com The Premier of the 92md session: Jennifer Kerr (780) 668-7892 premier@tuxis.org The Executive Director of the Alumni Society: David Marriott (780) 986-0056 dcm90@telus.net

Please complete both sides of this form, include cheque or money order for $50.00 deposit payable to the: TUXIS Parliament of Alberta Alumni Society, and forward to: c/o Benjamyn McKay #113, 9007 106A Avenue Edmonton, AB T5H 3Y7