Student Sponsorship Program Form

1. I certify that the information given above is true, correct, completed, and understand that it may be subject to verification. I hereby authorize Human Resource Development Canada to release information about the status and
benefit rate of Employment Insurance claim to Kivalliq Inuit Association to determine my eligibility for the program
and/or for alternative income support. This authorization will remain UNLESS I have given written instruction to cancel
authorization.

2. I hereby authorize Kivalliq Inuit Association to release and or request information as required from Nunavut
Government Department of Family Services, Department of Education Financial Assistance for Nunavut Students
(FANS), or other funding organizations, my childcare provide, and my landlord to determine my eligibility for the
program and for verification purposes throughout the duration of the program.

3. You may have access to information (under the Access to Information Act) that we maintain about you and may
request to see it upon one day’s written notice of such a request. Be reminded that Kivalliq Inuit Association is merely
a custodian of the information gathered on clients and that all information is the sole property of Human Resources
Development Canada. You are NOT entitled to take possession of your file, but you may request to see, add, or change
information therein.

4. I authorize Kivalliq Inuit Association at any time to request for information regarding my academic progress including
enrollment confirmation, education costs and transcripts from the education institution that I will be attending.

By signing this application form, you have read and understood the DECLARATION & AUTHROIZATION TO RELEASE
INFORMATION written on this form.