Kanesatake Education Center

New Student

Re-Enrollment

Student Information

Band Number: 069

Date of birth

Sex: Male Female

Have You Been Living in Canada for the last 12 months? Yes No

Surname:

First:

Second:

Home address:

Mailing address:

Email:

Phone #:

Emergency Contact Person:

Phone #:

Student profile

Single

Married/Common Law with Employed Spouse

Single Parent

Married/Common Law with Dependant Spouse

Number of Dependants (under age 18 or 18 to 21 if in high school)

List Dependants living with you

Name

Relationship

Date of Birth

Name

Relationship

Date of Birth

Name

Relationship

Date of Birth

Name

Relationship

Date of Birth

Name

Relationship

Date of Birth

Education Plan

Attendance

Full Time
Part Time

Program Level

Level I-College
Level II Undergraduate (i.e. B.A., B.ED.)
Level III Graduate or Professional (i.e. M.D., M.A.)
Level IV Doctoral (i.e. PhD’s)

Graduation Date

Program

Institution

Address

Length of Program (yrs)

Year of Study (i.e. 1st yr. Of 3 yrs.)

Semester applying for: Fall & Winter

Fall only

Winter only

Summer

Semester Period for this Application

to Fall Semester

to Winter Semester

to Summer Semester

I understand the following conditions for sponsorship by the Kanehsatake Education Centre. All information will be held in strict confidence and without prejudice.

To fill out all required confidential forms including: application forms, Consent to Request Information and Consent to Release Information.
To attend classes regularly and consistently.
To adhere to college/university regulations and meet the grade requirements set forth by the institution I am attending.
To provide the Kanehsatake Education Centre with a copy of my final grades at the completion of each semester.
To notify the Kanehsatake Education Centre if I withdraw from the institution, a course or transfer to another program.
To meet or exceed the minimum grade requirements of the institution, and understand that if I do not meet these requirements, my funding will be cancelled.

I declare that all of the above information is complete, true and accurate and I agree to inform the Kanehsatake Education Center of any changes, which may affect my eligibility for allowance. I also declare that I have read and understood all definitions, rules and guidelines.

Signature

High School Graduate :

Yes

Last Year Attended High School :

History of previous post-secondary education (start with last institution attended)

Institution	Address (include province)	Program	Dates attended	Graduated(Y/N)

Personal Information

First Name

Middle Name

Last Name

Home Address

Telephone Number

Academic Address (if different from home)

Telephone Number

Date of Birth

Student Permanent Code

Education Institution

Telephone Number

CONSENT TO REQUEST INFORMATION

I, , provide my consent, as may be required, to allow the Kanehsatake Education Centre, Post-Secondary Program, to request copies of information from employers, all sources of income, educational and employment and training institution(s): federal, provincial, and Kanehsatake government offices/agencies. This consent is intended to allow the Kanehsatake Education Centre, Post-Secondary Education Program to verify information to determine my eligibility to receive Education Assistance.

CONSENT TO RELEASE INFORMATION

I, , provide my consent, as may be required, to allow the Kanehsatake Education Centre, Post-Secondary Education Program, to release information and provide copies of documentation to educational and employment and training institution(s) and federal, provincial and Kanehsatake government offices/agencies. This consent is intended to allow the Kanehsatake Education Centre, Post-Secondary Education Program to provide information so that my eligibility for other assistance (including employment) may be determined and to confirm any assistance received through the Kanehsatake Education Centre, Post-Secondary Education Program.

SIGNATURE

This signed consent is valid until

Dated this day of

Application for Post-Secondary Financial Assistance

Student Information

Student profile

Education Plan

Personal Information

CONSENT TO REQUEST INFORMATION

CONSENT TO RELEASE INFORMATION

SIGNATURE

Application for Post-Secondary
Financial Assistance