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Dä̀kwä̀kä̀daHaines Junction

ShadęlChampagne

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Lu ghäKlukshu

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Post Secondary Education & Training Application

Name

First Middle Last

Date of Birth

DD slash MM slash YYYY

Social Insurance Number

Status Number

Home Address

Street Address Address Line 2 City Province Postal Code

Mailing Address (if different)

Street Address Address Line 2 City Province Postal Code

Phone/Cell

Gender

Email

Are you CAFN Member?

Yes

No

Spouse of CAFN Member?

Yes

No

First Nation

Marital Status

Single, independent

Single live w/parents

Married w/employed Spouse

Dependant Spouse

Widowed

Separated

Number of dependant Children

Learning or physical disability?

Do you have Drivers Licence?

Yes

No

Are you able to obtain a Driver Licence?

Yes

No

What is the last secondary grade that you completed?

What school did you attend?

Are you employed?

Yes

No

Type of employment

Full Time

Part Time

Seasonal

Employer

Employer contact

Are you currently on Employment Insurance Benefits (EI)?

Yes

No

How many EI elegible hours do you currently have?

When was the last time you received EI payments?

What certificates/Programs have you completed in the past? (Provide name and date)

Has CAFN provide you with founding for courses that were not completed?

Yes

No

What Eduction/Training are you applying for?

Name of the Program/Course Provider

Is it an accredited Institution?

Yes

No

Start Date of the Program/Courses/s

DD slash MM slash YYYY

End Date of the Program/Courses/s

DD slash MM slash YYYY

Do you have the prerequisites for the Program/Course/Training?

Yes

No

What do you need to qualify?

What are your plans after completing?

What are your strengths that will help you succeed with this program?

Support Required

Estimated Tuition Amount (per year)

Childcare

Tuition

Books

Accommodation

Travel

Meals

Wage Subsidy

Training Allowance

(Only applicable if training is more than 15 days+)

What additional financial or program support do you require to be successful?

What can you give back to CAFN/the community in the spirit of reciprocity?

Consent

I understand that by sending this application I the applicant; am aware that I am authorising Champagne Aishihik First Nations Education Depertment to release information contained to ESDC/Service Canada and the Council of Yukon First Nation and related Canadian Institutions and/or Employers and I am aware that any involved Institutions may contact me directly about the provided information herein.

Signature

Date

DD slash MM slash YYYY

Applicant Check List

Course Information and Dates

Copy of Registration/ Canadian Education Institution Signed Application

Submitted Copies of all completed Certificates and/or Other pertaining information/documents

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HAINES JUNCTION OFFICE

#1 Allen Place, P.O. Box 5310
Haines Junction, YT Y0B 1L0
867-634-4200

WHITEHORSE OFFICE

304 Jarvis Street
Whitehorse, YT Y1A 2H2
867-456-6888

COMMUNITY BUILDINGS

Takhini Hall 867-667-6701
Da Ku Store 867-634-3307
Youth Center 867-634-2012
Mun Kų 867-634-7001
Champagne Hall 867-634-2336
Klukshu Hall 867-634-2342

contactus@cafn.ca

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