Name *

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Last Name

Phone *

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Birth Date *

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Address *

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Emergency Contact Number *

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Gender *

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Member of a Visible Minority *

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Were you registered as a full-time student in the previous academic year? *

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Are you registered and/or intend on returning back to school full-time in the upcoming academic year? *

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By checking off this box, I confirm that all of the information I have provided is complete and correct. *

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