Western University

Student Declaration of Indigenous Citizenship or Membership

Student Last Name or Surname:

Student First Name or Given Name:

Western Student Number:

Email:

Reason for Affirmation:

Please specify the purpose for which you are declaring Indigenous citizenship or membership. This includes a role, opportunity, fellowship, award, bursary, scholarship, and/or initiative. Be sure to list the exact name(s) of the opportunity and/or opportunities you are being considered for.

I understand that the role, opportunity, fellowship, award, bursary, scholarship, and/or initiative for which I am being considered is intended specifically for an Indigenous student at Western University or Indigenous students will be given preference. As such, I solemnly declare that I hold Indigenous citizenship or membership as demonstrated by the submission of the following:

A student's detailed statement of relational positionality¹, which includes a demonstration of lived experience² and includes details about their lineal descent³, as per guidance provided in the University's Procedure for Policy 1.58 - Affirming Declarations of Indigenous Citizenship or Membership; and
A student's proof of membership to the Indigenous Nation claiming them as per the Procedure for Policy 1.58 - Affirming Declarations of Indigenous Citizenship or Membership.

I understand that should my claim of Indigenous citizenship or membership not be affirmed under this Procedure and associated Policy and not successfully appealed, my application will be rejected and my candidacy terminated.

I further understand that providing false or misleading information about Indigenous citizenship or membership may result in an investigation led by Western University and, if the concerns are well founded, corrective action may be taken, including the termination/revocation of my role, opportunity, fellowship, award, and/or relevant initiative that has been designated explicitly for an Indigenous student (or for which preference is given), and/or that I may be subject to proceedings under applicable University policy, including Scholastic Discipline for Undergraduate Students, the policy on Scholastic Discipline for Graduate Students or the Code of Student Conduct, as applicable.

Next Steps - Affirming Declarations of Indigenous Citizenship or Membership

Please upload these three required documents below.

A detailed statement of relational positionality¹, which includes a demonstration of lived experience² and details outlining my lineal descent³

Choose a file:
Two documents demonstrating proof of citizenship or membership to the Indigenous Nation claiming me

Document #1: Document #2:
Note: Allowed maximum size for each file is 10Mb
Allowed file types: jpg,jpeg,png,gif,pdf,doc,docx

If you have circumstances that prevent you from providing the requisite documentation, please send an email message requesting assistance to indigenous.affirmation@uwo.ca.

By clicking on this box, I hereby certify that all statements are complete and correct. I understand that if I make an intentionally false declaration of Indigenous citizenship or membership, I will not be eligible to apply for any future or subsequent roles (i.e., any non-Indigenous designated role) at Western University.

To verify that you are a human, please enter the text below:

For more information, contact:

Indigenous Student Centre (Office of Indigenous Initiatives)
Western Student Services Building, Room 2100
1151 Richmond Street, London, ON N6A 3K7
Telephone: 1-519-661-4095; Toll free: 1-888-661-4095
Fax: 1-519-850-2578 (confidential fax)
Email: indigenous.affirmation@uwo.ca
Website: https://indigenous.uwo.ca/students

¹ Positionality refers to how differences in social position and power shape identities and access in society ( https://indigenousinitiatives.ctlt.ubc.ca/classroom-climate/positionality-and-intersectionality/).

² Lived experience is the "personal knowledge about the world gained through direct, first-hand involvement in everyday events rather than through representations constructed by other people. It may also refer to knowledge of people gained from direct face-to-face interaction rather than through a technological medium" (https://www.oxfordreference.com/).

³ The term lineal consanguinity describes blood relationships where one person is a direct descendant or ascendant of another, meaning they are related in a straight-line family connection like a parent-child or grandfather-grandchild (https://www.law.cornell.edu/wex/lineal_consanguinity#:~:text=Lineal%20consanguinity%20is%20the%20blood,father).

The personal information on this form is collected under the authority of The University of Western Ontario Act 1982, as amended. To view the complete Personal Information Collection Notice, visit the online Academic Calendar at: http://www.westerncalendar.uwo.ca