Student for a Day Application

Please fill out this registration form and embedded consent waivers in their entirety. The Student For a Day program runs from September-November and January-March, and is individually tailored to your availability.

Name(Required)

First Last

Email(Required)

Date of Birth(Required)

Day

Month

Year

Home Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone Number(Required)

Do you have any allergies or dietary restrictions?(Required)

This program includes a free lunch in our Residence Cafeteria, who can accommodate for most allergies and dietary needs/restrictions.

Yes

Please list allergies and/or dietary restrictions(Required)

Do you have mobility and/or other special physical requirements?(Required)

Yes

Please provide details on your mobility and/or other special physical requirements(Required)

Academic Information

Are you currently enrolled in High School?(Required)

Yes

High School(Required)

Current Grade(Required)

Please Specify(Required)

Example: enrolled at ___ University/College, taking a gap year, working full-time etc.

Expected year/term entry to University(Required)

Example: Fall 2020, Winter 2021 etc.

Estimated Academic Average(Required)

Program Preferences

Please rank your program choices from 1-3 below, 1 being your first preference.

First Choice(Required)

Second Choice(Required)

Third Choice(Required)

Availability

A typical university day could include scheduled coursework between the hours of 8:30am and 5:30pm.

Do you know the exact date(s) and time(s) you would like to request?(Required)

Are you requesting specific date(s) and time(s), or would like us to let you know our availability based on days/times provided?

Yes, I know the exact date(s)

No, will provide availability instead

Preferred Date 1(Required)

Program offered Monday-Friday

MM slash DD slash YYYY

Preferred Date 2

Program offered Monday-Friday

MM slash DD slash YYYY

Preferred Date 3

Program offered Monday-Friday

MM slash DD slash YYYY

How soon would you like to attend this program?(Required)

Within the next 2 weeks

Within the next month

This Academic Term (Sept-Dec or Jan-Apr)

This Academic Year (Sept-Apr)

Please select what days of the week you are available(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Do you have any specific date or time restrictions?(Required)

Example: only available 9am-12pm, not available Dec 1 etc.

Would you like any of the following to be included in your day?(Required)

Select all that you would like to be included in your day.

Meeting with Professor

Lab Facilities Tour (Engineering & Design labs)

Campus Tour

None of the above

Do you request a student guide of a specific gender?(Required)

If yes, please indicate the gender of the guide you’d like to request. Or, indicate “no preference”. At Carleton University, we recognize and respect the importance of privacy. Personal information that we collect is kept confidential. In accordance with section 41 of the Freedom of Information and Protection of Privacy Act, Carleton University will only use the information in its custody or control in the following circumstances: where the individual identifies the particular information and consents to its use; for the purpose for which it was collected or a consistent purpose (i.e. a purpose which the individual might have reasonably expected). Please read our full Privacy Notice at admissions.carleton.ca/privacy.

How did you hear about this program?(Required)

Please select all that apply

Carleton Event (SEDS, Fall Open House, March Break Day etc.)

Google Search

Carleton Website

Word of Mouth (Friend/Family etc.)

High School Visit or Fair

Phone Call

Other

Other Please Specify(Required)

Consent Waivers

Please read the following carefully when checking off each section in this waiver of liability and informed consent agreement.

Disclaimer Clause(Required)

I consent

The Governors of Carleton University AND the Faculty of Engineering & Design, their agents, officials, officers, directors, employees, volunteers, contractors, servants or representatives (hereinafter refer to as “The University and Faculty of Engineering & Design”) are not responsible for any death, injury, loss or damage of any kind suffered by any person while participating in Carleton Engineering Student for a Day Program (hereinafter refer to as “SFD”) and all related activities of SFD, including injury, loss or damage which might be caused by the negligence of THE UNIVERSITY AND THE SCHOOL.

Description of Risks(Required)

I consent

In consideration of my participation in SFD program and all related activities, I acknowledge that I am aware of the possible RISKS, DANGERS AND HAZARDS associated with SFD program and all related activities including THE POSSIBLE RISK OF SEVERE OR FATAL INJURY TO MYSELF OR OTHERS. These risks include, but are not limited to: (1) Risks associated with travel to and from all venues of the various components including transport by public or private motor vehicle which could include but are not limited to an accident resulting in severe physical injuries or death; (2) Food-related illness resulting from any meal arranged for me by SFD organizers; (3) Muscular injuries and soft tissue injuries, broken bones, bruises, scrapes, cuts, sprains, dislocation, head, facial eye and/or dental injuries which might result from participation in SFD; (4) Injuries resulting from falling or being knocked down or steep steps where a fall may cause injury or death; (5) Injuries resulting from rough terrain, failure to see an obstacle, failure to negotiate a turn, etc.; (6) Injuries resulting from walking on a hill, slipping and/or falling; (7) Injuries resulting from burns or reaction to or from chemicals, solvents or other materials used in the labs (8) Injuries resulting from malfunctioning of equipment or misuse of equipment whether owned, designed or operated by myself or the staff of THE UNIVERSITY or the Faculty of Engineering and Design; (9) Changes in weather or temperatures which may result in hypothermia, frostbite, windburn, sunburn, colds or flu; (10) Death, injuries or illness resulting from failure to follow directions from those in charge of the program and all related activities; (11) The risks associated with returning to my residence after participating in the program and/or related activities; and (12) Other risks associated with being a spectator of or being present at a crowded, outdoor or indoor event.

Medical/Health & Travel Insurance(Required)

I consent

I freely accept and assume all responsibility to provide myself with medical/health and travel insurance coverage.

Medical Conditions(Required)

I consent

I agree to advise the organizers of the trip prior to the start of the event of any existing medical conditions or injury.

Indemnification & Release of Liability(Required)

I consent

In return for allowing me to voluntarily participate in the program and all related activities, I agree: (1) TO ASSUME AND ACCEPT ALL and ANY RISKS arising out of, associated with or related to my participation in the SFD program and all related activities, even though such risks may be caused by the negligence of THE UNIVERSITY OR faculty of engineering and design; (2) TO BE SOLELY RESPONSIBLE FOR ANY and ALL INJURY, LOSS OR DAMAGE which I might sustain while participating in THE UNIVERSITY OR faculty of engineering and design program and all related activities, even though such injury, loss or damage may have been caused by the negligence of THE UNIVERSITY OR faculty of engineering and design (3) TO HOLD HARMLESS AND INDEMNIFY THE UNIVERSITY OR faculty of engineering and design from any and all liability for any damage to the personal property of, or personal injury to, any third party resulting from my participation in the SFD program and all related activities; (4) TO HOLD HARMLESS, INDEMNIFY AND RELEASE THE UNIVERSITY OR faculty of engineering and design, their officers, directors, agents, volunteers, employees and representatives from liability for any and all claims, demands, actions and costs which might arise out of my participation in SFD program and all related activities, even though such claims, demands, actions and costs may be been caused by the negligence of THE UNIVERSITY OR faculty of engineering and design

Code of Conduct(Required)

I consent

The Faculty of Engineering, Carleton Engineering Student For A Day Program entails visiting the university campus for a day of activities, eating a meal provided by the university, attending lectures and participating in related engineering activities as determined by the organizers: (1) I agree not to bring or consume any alcohol or illegal substances for the duration of this event (2) I will behave responsibly and appropriately and adhere to any rules of conduct laid down by the organizers of this visit

Signature (Parent/Guardian or Participant, if 18+)(Required)

Please fill in (if under 18) your parent/guardian’s first and last name, and phone number we can contact them if needed. By filling in this section, you consent that your parent/guardian is aware of your registration for Student For a Day. If you are over 18, please sign section this with your details instead (first, last name and phone number).

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