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District of Kitimat Accessibility and Inclusion Committee (AIC) Application Form

Within this form, we invite applicants to self-identify and share personal information if they are comfortable doing so.

The District of Kitimat will use the information provided to support committee member selection. Your application will be confidential and only reviewed by District Council for the purpose of appointing members to the AIC.

We will strive to accommodate all members to ensure they are able to fully participate, if you have a specific accommodation request, or would like more information about the AIC, please contact Marli Penner at mpenner@kitimat.ca or by phone at 250-632-8915.

Physical copies of this form are also available at all District of Kitimat facilities.

This information is collected for administrative purposes under section 26 of the Freedom of Information and Protection of Privacy Act (FIPPA). The information will be used and maintained for the purpose it was collected and in accordance with FIPPA.

Applicant Name

Mailing Address

Phone Number

Email address

What target group(s) do you represent?

A person from another equity-deserving group

An Indigenous person

A member of a disability-serving organization

A parent or guardian supporting someone with a disability

A person with a visible or invisible disability; including physical, cognitive, perceptual, and/or mental health disabilities

If you selected "member of a disability-serving organization" please indicate which organization. (Skip if not applicable)

Why do you want to join this committee?

Describe any experience or skills that may assist the committee when dealing with the identification, removal and prevention of barriers as they relate to accessibility.

What related skills, knowledge, or experiences do you have that may benefit this committee?

What accomodations do you require, if any?

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District of Kitimat Accessibility and Inclusion Committee (AIC) Application Form

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