General ReconciliACTIONs Form

First Name:

Last Name:

Email:

What DWF program are you affiliated with

School, Organization, Company, Community (if applicable):

If other, please explain:

Did this event happen over one day or multiple days?

One DayMultiple Days

Date of Third-Party Initiative/Event:

If the event took place over multiple days please indicate the start and end dates:

Start Date:

End Date:

Number of Participants:

Tell us about your ReconciliACTION

Where do you believe this reconciliation most closely aligns with from the below selection:

Taking steps to enhance respect and empathy for Indigenous peopleLearning about Canada's true history and its impact on Indigenous Peoples and communitiesReflecting and changing my thought process on current affairs with Indigenous Peoples and communitiesTaking meaningful and actionable steps toward reconciliationDeveloping meaningful relationships with Indigenous PeoplesWorking beyond myself to impact my community or workplace culture, values and/or policies

Did you work with an Indigenous artist or vendor for this initiative?

YesNo

If so, please feel free to share their name or website with us so we can recommend them to partners in your area:

If a Fundraiser, Total Amount Raised

Please include links to any social media posts about the event/initiative:

Please provide any feedback regarding working with DWF on this initiative:

Is there any additional support DWF could have provided to help with the success of your event/initiative? (Ex. Additional resources, etc.)

Upload your reconciliACTION

I, hereby certify and give my permission for the Gord Downie & Chanie Wenjack Fund (DWF) and/or partners to use the uploaded recording, film, photograph, audio or/and video (known from here on in as “WORKS”) and to display, publish or distribute these Works for the purpose of publishing, posting on the DWF website, posting in Legacy Schools, Legacy Spaces, at public events, in educational materials, posting on social media sites and/or for broadcasting on television or radio as determined by DWF. I hereby waive any right to approve the use of these Works now or in the future, whether the use is known to me or unknown, and I waive any right to any royalties related to the use of these Works. I understand that the Works may appear in electronic form on the internet or in other publications outside of DWF’s control. I agree that I will not hold the DWF responsible for any harm that may arise from such unauthorized reproduction. Educators submitting on behalf of minors are expected to have parent/guardian waivers signed as per school rules and kept on file. By clicking this button you agree that all of this has been completed and the photos are free for DWF to use.