Registration – CCGP Learning Academy

1.0 Student Personal Information

1.1 First Name *

Middle Name

Last Name

1.2 Gender *

Male
Female

1.3 Date of Birth

1.4 Address

Address Line 1

City

State / Province / Region

Postal Code

Country

1.5 Phone

1.6 Status in Canada *

1.7 Country of Birth

2. 0 Student Medical Information

2.1 OHIP Number

2.2 Any Medical Condition (allergies, medication, etc.)

3.0 Student other information

3.1 Has the student ever been expelled from school?

Yes
No

3.2 Does the student have brother or sister in the school?

Yes
No

If yes, please provide their names and their grades

3.3 Mother Language *

3.4 Language(s) spoken at home

4.0 Student School Details

Total years spent in school (Fill in the space below by starting with the last school attended)

4.1 Last Year of Enrollment

4.2 Grade/Level

4.3 Name of the School

4.4 City

4.5 Country

5.0 English Language Proficiency

IELTS Score/Other

Reading

Writing

Listening

Speaking

6.0 Parent/Legal Guardian

6.1 Full Name of the Parent *

6.2 Relationship

6.3 Is your home mailing address same as the student?

Yes
No

If no, please provide full address (street, city, province, country, postal code)

6.4 Do you have access to student?

Yes
No

7.0 Emergency contact

7.1 Home Phone Number

7.2 Cell Phone Number

7.3 Office Phone Number

7.4 Email Address *

8.0 Upload Document

8.1 Upload any document

Allowed File Extension .png, .gif, .jpg, .doc, .xls, .ppt, .pdf

9.0 Terms and Conditions

9.1 I agreed following Terms & Conditions *

Terms & Condition *

1. Admission depends on course avilability

2. A one time registratoin fee is $50 (non refundable)

3. Class may cancel if enrollment is less than five students

4. CLA has right to cancel, delay and change schedule if necessary