2014 NASIMCO Youth Leadership Retreat: Registration Form
Making Your Voice Count: Thinking Outside The Box

The NASIMCO Youth Leadership retreat is an annual program organized to empower youth to explore and develop leadership opportunities. The retreat combines facilitated workshops, debates, dialogue and recreational activities in order to optimize learning opportunities for all participants. The retreat will be held at the Copperdome Lodge (copperdomelodge.com) in the picturesque area of Pemberton, British Columbia. The goals of the retreat are as follows:

• To enable participants to explore assumptions, beliefs and attitudes about themselves, and the environments in which they operate

• To develop the capacity for social and political leadership amongst the youth

• To facilitate the spiritual and social upliftment of youth in North America

• To enable the youth to realize their full potential
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2014 Retreat Information
When: Fri. Aug. 29th (Morning) - Mon. Sept 1st (Afternoon)
(Labor Day Long Weekend)

Who: Ages 18 to 25

Where: Copperdome Lodge in Pemberton, British Columbia

Cost: $200 per person (sponsorships available)

Transportation: Bus service to & from the retreat facility will be provided. Pick up and drop off location will be Al-Zahra Islamic Centre. For participants who are applying from out of town, transportation will be arranged to & from the Vancouver airport (YVR). Additional accommodation (1 night before or after the retreat) can be provided upon request.

**Space is limited. Deadline to register is July 1st 2014**

Note: Applicants are asked not to book their flights until your spot at the retreat is confirmed. Applicants who do not receive a spot or need to cancel, refunds are available until July 31st, 2014. Exceptions are made for emergencies. If there are any questions please contact us at retreat@nasimco.org. Thank-you!
Registration Form
Name *
Sex *
Age *
Email *
Phone Number *
Address *
Occupation *
What community do you affiliate with or belong too? *
T-shirt Size *
Receive a complimentary retreat t-shirt. If you would like a long-sleeve or any other style please specify under "other" (with sizing) and we will try our best to accomodate you
Emergency Contact Name *
Relationship to you: *
Emergency Number *
Dietary Requirements
Clear selection
Disability Accommodations:
The NASIMCO Retreat Team actively encourages applications from youth with disabilities.

Should you require an accommodation in order to participate in this retreat, please email us at retreat@nasimco.org 

Additional Information
In 250 words or less, please complete the following questions in support of your application:
What are you passionate about? *
What activities, initiatives or programs are you currently involved in outside of work or school? If you are not involved, then what would you like to be involved in? *
What does “Thinking outside the Box” mean to you? *
Why are you applying to attend the 2014 Retreat? What do you expect to get out of the 2014 Retreat? *
Which of the following social issues in Canada would you be interested in learning and discussing about at this year's youth retreat? *
Check all that you feel passionate about or the least want to gain insight on how to combat such issues
Required
In your view, what are the current issues, needs, pressures or roadblocks facing the youth of your community? *
Do you feel the youth have a voice or are actively involved in your community? If yes, please provide examples of the programs or events they are involved in. If no, why do you think they are not involved? *
At the end of this retreat, will you make time to apply your knowledge and work on projects that will benefit your community? If yes, please explain how you would plan to *
Waiver
I take full responsibility in participating in the activities made available at this camp.

Permission is granted for me to receive emergency medical treatment if needed the cost of which will be paid by me.  I hereby release and discharge NASIMCO, its officers, all its affiliated entities, volunteers, organizers, chaperones and representatives from any and all liability, claims, demands, damages, costs, expenses, personal injuries, and/or loss suffered by me in connection with my participation in the camp.

I agree that the grant and release contained therein binds me to all of its terms.

I understand and agree to the waiver outlined above.

Participant Name: *
Date: *
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