STUDENT'S PERSONAL INFORMATION

Last Name: First Name: Birth Date: Gender: Mailing Address: City, Town: Province: Postal Code: Telephone: Current Citizenship Status (check one): Canadian Citizen Permanent Resident

ACADEMIC INFORMATION - SCHOOL LAST ATTENDED

Name: # of Years to Date: Address: Telephone: Date of Exit: Last Grade Completed: Average:

INFORMATION FROM PARENTS/GUARDIANS:

Mother:

Last Name: First Name: Address (If Different From Above): Street: City: Province: Postal Code: e-mail: Tel. (Home): Tel (Work):

Father:

Last Name: First Name: Address (If Different From Above): Street: City: Province: Postal Code: e-mail: Tel. (Home): Tel (Work):

Date: