Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Gender

Male

Female

Other

Non-Binary

Aboriginal Ancestry

Status

Non-Status

Métis

Inuit

Please Indicate Your Interests: Check any that apply.

Day Time

Adult Graduation

Post-Secondary Upgrading

Virtual Classes

Please Indicate Your Interests: Check any that apply.

Evening

English

Math

EMERGENCY CONTACT INFORMATION

Who should be contacted in the case of an emergency?

First Name

Last Name

Phone

(###)

###

####