Application Form. First Name (as shown on government issued identification): Address (Please use your official utoronto address):

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1 Application Form Please complete the form below. Ensure the information provided matches the information on the government issued identification you will be travelling with. In addition to this form, you are required to submit a signed UTM Across Canada Medical Form and $250 first instalment payment by the application deadline in order for your application to be considered complete. The information on this form is collected in accordance with the Freedom of Information and Protection of Privacy Act (FIPPA) for the selection and logistical planning of the UTM Across Canada program. All applicants must be in good academic standing (minimum 1.5 CGPA). Applications will be considered on a first-come, first-served basis. General Information First Name (as shown on government issued identification): Middle Name (as shown on government issued identification): Last Name (as shown on government issued identification): Student Number: Address (Please use your official utoronto address): Gender: *Please note that most trips include shared gender accommodations (e.g.: participants sharing mixed gender bedrooms/bathrooms in a residence hall/hotel). Please contact us should you want more details or would like to discuss the arrangements.) Date of Birth (DD/MM/YYYY): Phone Number: Do you speak any languages other than English? Yes No If yes, please indicate your level of fluency (basic, moderate or fluent) for each language:

2 Language: Language: Language: Level of fluency: Level of fluency: Level of fluency: Program Choice Which experiences are you interested in? (Check all that apply) Nova Scotia & Prince Edward Island June 24-July 2, 2017 Quebec & Ottawa October 7-15, 2017 Ranking: If you selected more than one experience, please rank your choices in order of preference. We will use this section to offer alternatives should we not be able to accommodate your first preference. If you are only interested in one trip, please include only your first preference. Preference 1 Preference 2 Identification Information For the information below, please ensure that you are using the details of the government issued identification you will be travelling with. Identification Document Country of Issue: Type of Document: Expiry Date (DD/MM/YYYY):

3 Fitness Level Please include detail your fitness level below. To assess the fitness level required for each experience, please refer to the individual pages of the experiences you are interested in. Fitness level Not active (would have great difficulty walking for 30+ minutes) Barely active Somewhat active (no issue walking 2+ hours, but would find running for 15+ minutes difficult) Moderately active Very active (would have no issue hiking up a mountain) Please provide examples of how you keep fit in everyday life: Thinking Ahead Why would you like to participate in the experiences you have selected?

4 Why should you be selected to participate in this experience? What do you expect to get out of this experience? How do you intend to share what you have gained from this experience when you return?

5 Please tell us how you feel about the following program elements. 5 means most excited and 0 means not excited at all. Finding yourself off the grid in a rural, rarely traveled to place: Participating in nature based activities such as hikes and fishing: Visiting National Historical sites, parks, and museums: Participating in cultural activities (e.g.: markets, artisan goods, Celtic music, French language etc.): Trying new and unfamiliar foods: Sleeping in shared accommodations (2-4 people per room.): Having infrequent access to wifi, or cell phone service: Spontaneous, ever adaptive itinerary: Emergency Contact Information Emergency Contact First Name: Emergency Contact Last Name: Emergency Contact Phone Number: Emergency Contact Alternate Phone Number: Emergency Contact Relationship to you:

6 Terms of Participation Participants must complete the required application by the specified deadline as found on the UTM Across Canada website; Participants must accurately complete and submit the UTM Across Canada medical form by the specified application deadline. When required, the participant must submit an additional medical clearance form signed by a physician; Participants must meet all outlined payment deadlines and participate in all the required sessions/events leading up to the travel experience as well as reintegration and reflection events or activities held after the experience. This may include training sessions, pre- departure orientations, safety sessions, etc.; Participants will continue to adhere to the University of Toronto policies including but not limited to the Code of Student Conduct and the Policy and Procedures: Sexual Harassment; Participants are responsible for familiarizing themselves and acknowledging the risk of the particular out-of-province activity, taking appropriate precautions as needed; Participants are responsible for making a self-assessment regarding appropriateness of participation; Participants must connect with the appropriate resource on campus and make any requests for accommodation within 30-days of the application deadline; Participants are responsible for obtaining and providing proof of their travel insurance at least 30-days prior to departure. Participants are responsible for determining the adequacy of their travel insurance and ensuring it meets their medical and experiential needs for the duration of the travel experience; Participants are responsible for obtaining appropriate travel documentation. Refunds will not be awarded for trip cancellations due to improper travel documentation; Participants agree to the sharing of their health and safety information with the University of Toronto staff members supporting the experience for use in the case of an emergency; Participants agree to the sharing of information between university services for matters related to their health and safety; Participants are responsible for obtaining any required immunizations, seeking medical advice as needed prior to departure and ensuring they have any required medication readily available to them during the experience; Participants are encouraged to purchase trip cancellation insurance.

7 Fees All applicants are required to submit a $250 non-refundable first instalment payment by the application deadline to be considered for participation in any of the UTM Across Canada travel experiences; All fees must be paid in full by the deadlines outlined on the UTM Across Canada website. Failure to meet payment deadlines may result in the cancellation of the applicant's offer of participation in the program with no refund of fees; The fees posted include flights (where applicable), local transportation, accommodation, and tours/activities listed in the corresponding itinerary; Fees associated with meals, travel insurance, additional optional tours/activities while away, medical exams, vaccinations, and any other additional costs are not included in the program fees; Participants will be held liable for any fees associated with damages caused to the facilities visited or used for accommodation during the travel experience; In the event that a participant is unable to continue traveling with the group as per the itinerary, the participant may be held financially responsible for all associated costs; All fees are to be paid in Canadian dollars. Fee Payment Schedule The fee payment schedule for all UTM Across travel experiences can be found under the Payments section. Refund Policy The $250 first instalment may only be refunded under the following circumstances: o In the event of a trip cancellation at the university's discretion based on health and safety concerns, insufficient enrolment in the program, or any other unforeseen circumstances; o In the event that the university is not able to extend an offer of participation to the applicant. All remaining fees are non-refundable. Should the participant face unforeseen circumstances prohibiting them from participating in the program, they should submit an appeal to the International Education Centre detailing their circumstances and provide any relevant documentation. At the discretion of the university, and under exceptional circumstances, fees not including the first instalment may be refunded under the following schedule: Description Refund Cancellation prior to the third instalment deadline. Partial refund of the second instalment paid minus a 3% administration fee. The first instalment is not refundable. Cancellation after the final instalment deadline and prior to the travel date. Partial refund of the second and fourth instalment paid minus a 3% administration fee. The first and third instalments are not refundable.

8 Signature I have read and understood the above conditions related to participation in the UTM Across Canada, and agree to be bound by these terms. Failure to comply may result in my termination from the program. Signature of Student: Print Name: Date: Signature of Witness (Mandatory; witness not employed by UofT): Print Name: Date: Notice of Collection of Information - Freedom of Information and Privacy Act The University of Toronto respects your privacy. Personal information that you provide to the University is collected pursuant to section 2(14) of the University of Toronto Act, The information is being collected for the purpose of administering admissions, registration, academic programs, university-related student activities, activities of student societies, safety, financial assistance and awards, graduation and university advancement, and reporting to government agencies for statistical purposes. At all times it will be protected in accordance with the Freedom on Information and Protection of Privacy Act. If you have questions, please refer to or contact the University Freedom of Information and Protection of Privacy Coordinator at , McMurrich Building, room 201, 12 Queen's Park Crescent West, Toronto, ON, M5S 1A8.