STUDENT INFORMATION FORM

Participant Information


Participant's Full Name

Date of Birth (M/D/Y)

Age

Gender
MaleFemale


Address

City

Province

Postal Code

Program/School


Parent/Guardian Information


Mother's Full Name

Occupation

Home Phone

Mobile Phone

Father's Full Name

Occupation

Home Phone (If different from Mother's)

Mobile Phone

Parent's Primary Email Address


Emergency Contact Information


Full Name

Relationship

Home Phone

Mobile Phone


Community Support Worker/Caregiver Information (whom will accompany participant to classes)


Full Name

Phone

Email

Program(s) of Choice - Please select program(s) of choice. If selecting multiple, press Ctrl while clicking on program(s)

Goals of Program

How did you hear about our program? (please be specific)



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