GENERAL INFORMATION First Name Last Name Birthdate Gender Marital (mm/dd/yyyy) Status F M Identifies as: How did you hear about our department? Current Phone # OK to leave Alternate Phone # OK to leave message   message School Email Permission to Contact  Alternate Email Permission to Contact  ADDRESS INFORMATION Unit/Suite Address While in School City Province Postal Code Living on Campus EMERGENCY CONTACT Name Cell Phone Relationship Permission to Contact DEMOGRAPHIC INFO First Nation/Inuit/Metis Languages Spoken: of Birth? International Student English __________________________________ LGBTQ French Newcomer (under 3 years) Other (please specify): ACADEMIC INFORMATION Program Semester Campus Status: Full time Alumni Other Part time Prospective Reduced Course Load Second Career International Student COLLEGE SERVICES YOU ARE CURRENTLY ACCESSING Counsellor Athletic Centre Accessibility Advisor Learning Strategist Case Manager International Centre Registrar First Generation/Year/Pear Mentor Testing Services Adaptive Technologist Peer Services Campus Safety & Security Career/Co-op Academic Upgrading Continuing Education Student Housing SAC Aboriginal Resource Centre (Residence & Off-Campus) COMPLETED BY: _____________________________________________ DATE:________________________________________
GENERAL INFORMATION First Name Last Name Birthdate (mm/dd/yyyy) Gender Marital Status F M Identifies as: How did you hear about our department? Current Phone #  OK to leave message Alternate Phone #  OK to leave message School Email  Permission to Contact Alternate Email  Permission to Contact ADDRESS INFORMATION Address While in School Unit/Suite City Province Postal Code Living on Campus EMERGENCY CONTACT Name Cell Relationship Phone Permission to Contact DEMOGRAPHIC INFO First Nation/Inuit/Metis International Student LGBTQ Newcomer (under 3 years) Languages Spoken: English French Other (please specify): of Birth? __________________________________ ACADEMIC INFORMATION Program Semester Campus Status: Full time Part time Reduced Course Load Alumni Prospective Second Career Other International Student COLLEGE SERVICES YOU ARE CURRENTLY ACCESSING Counsellor Learning Strategist Registrar Adaptive Technologist Career/Co-op Student Housing (Residence & Off-Campus) Athletic Centre Case Manager First Generation/Year/Pear Mentor Peer Services Academic Upgrading SAC Accessibility Advisor International Centre Testing Services Campus Safety & Security Continuing Education Aboriginal Resource Centre COMPLETED BY: _____________________________________________ DATE:________________________________________
Intake-Consent-Form-Georgian-College.docx