CrossRoads Learning Centre
Unit H – 2211 McPhillips Street Fax: (204) 694-0779
Winnipeg, MB R2V 3M5 Email:
Telephone: (204) 953-2030 Website:
GRADE 12 MATURE STUDENT DIPLOMA PROGRAM
In Partnership with Manitoba Institute of Trades and Technology (formerly Winnipeg Technical College)
REGISTRATION FORM
How did you hear about our program?
Flyer Friend Newspaper Other – Please Specify______
Freedom of Information and Protection of Privacy Act. The personal information you provide is voluntary and confidential and will be used to assess your eligibility and suitability for the program. It is collected under the authority and regulations of the Manitoba Public School Act and the Education Administration Act. The information will be used for the enhancement of education programming, for the completion of funding applications, and for the completion of periodic reports as required by the provincial authorities.
Name______
Family NameFirst Name Middle Name
Previous Names ______
(if applicable)
Current Address ______
No. & Street
______
City & Province Postal Code
Telephone______Email ______
Home Phone # Cell Phone # Work Phone #
ResidencyI currently reside in ______School Division.
Personal DataDate of Birth:______Age______ Male Female
Month Day Year on June 30, 2018
Ancestry Status Band ______
Metis Non-Status Inuit Visible Minority Other
What is your first language? (English, Filipino, Portuguese, Ojibwa, Mandarin, Urdu, Polish, etc.) ______
Canadian Language Benchmark______Date of Immigration ______
(if applicable) (if applicable)
Are You a Canadian Citizen □ □ Are You Eligible to Study in Canada □ □ Do You Have a Permanent Resident Card□ □ Yes No Yes No Yes No
Emergency Contact Person______
Contact Name Phone #
Medical concerns you care to share______
Family Status: Single Single Parent w/Children Under the Age of 6 Married/Equivalent
\
High School Education
Please check the last grade completed:
Date Completed: ______Indicate any partial grades completed: ______
7 8 9 10 11 12
Name(s) and Location(s) of school(s): ______
High School Upgrading
Have you received any upgrading or training since you left school? Yes No
If Yes, was it:
/Level Completed
/Date Completed
Adult Basic Education 8-10 11 12 ______
GED 10 11 12 ______
An Adult Learning Centre 10 11 12 ______
Literacy Program: Name of Program ______
Are you currently attending /enrolled in another Adult Learning Centre? Yes No
If Yes, Name of Centre: ______
If you have ever been enrolled in any post-secondary education, training programs or technical programs, please list them (college, technical institute, university, Centre for Aboriginal Human Resource Development, MB Metis Federation, etc.)
Institution / Program/Course / Date Of Attendance / Completion?Yes / No
Are you currently:
Employed full-time (30 hours per week or more) Employed part-time (less than 30 hours per week)
Unemployed (Actively seeking work) Unemployed (Not actively seeking work)
Receiving Employment Insurance Yes No
If Yes, have you met with an Employment Counsellor at the EI Office to discuss your training plan Yes No
Receiving Social Assistance Yes No If Yes, what is your Case # ______
Worker's Name ______Does your Worker know you've applied at CrossRoads? Yes No
Receiving Band Funding Yes No Counsellor's Name ______
What is your occupational goal? ______
I consent to the verification of any information supplied in this application. I certify that the statements made by me are true and to the best of my knowledge.
Signature: Date:
Please check all classes that you would like to register for. Note that during the day, only one class in each time slot is permitted, and in the evening only one class on Monday/Wednesday, and one class on Tuesday/Thursday is permitted.
Day Classes – First Quarter – September 18, 2017 – November 16, 2017Time / Days / Class /
9:00 a.m. – 12:00 p.m. / Monday – Thursday / Grade 12 English Language Arts Transactional
9:00 a.m. – 12:00 p.m. / Monday – Thursday / Grade 12 Chemistry
12:30 p.m. – 3:30 p.m. / Monday – Thursday / Grade 12 Essential Math
Day Classes – Second Quarter – November 20, 2017 – February 1, 2018
Time / Days / Class /
9:00 a.m. – 12:00 p.m. / Monday – Thursday / Grade 12 Applied Math
9:00 a.m. – 12:00 p.m. / Monday – Thursday / Grade 12 Psychology
12:30 p.m. – 3:30 p.m. / Monday – Thursday / Grade 12 Computers/Office Administration
Day Classes – Third Quarter – February 5 – April 12
Time / Days / Class /
9:00 a.m. – 12:00 p.m. / Monday – Thursday / Grade 12 Essential Math
12:30 p.m. – 3:30 p.m. / Monday – Thursday / Grade 12 Biology
12:30 p.m. – 3:30 p.m. / Monday – Thursday / Grade 12 English Language Arts Transactional
Day Classes – Fourth Quarter – April 16, 2018 – June 14, 2018
Time / Days / Class /
9:00 a.m. – 12:00 p.m. / Monday – Thursday / Grade 12 English Language Arts Transactional
12:30 p.m. – 3:30 p.m. / Monday – Thursday / Grade 12 Applied Math
Evening Classes – First Semester – September 11, 2017 – December 21, 2017
Time / Days / Class /
6:00 p.m. – 9:30 p.m. / Monday & Wednesday / Grade 12 Pre-calculus
6:00 p.m. – 9:30 p.m. / Monday & Wednesday / Grade 12 Applied Math
6:00 p.m. – 9:30 p.m. / Monday & Wednesday / Grade 12 English Language Arts Transactional
6:00 p.m. – 9:30 p.m. / Tuesday & Thursday / Grade 12 Chemistry
6:00 p.m. – 9:30 p.m. / Tuesday and Thursday / Grade 12 Biology
6:00 p.m. – 9:30 p.m. / Tuesday & Thursday / Grade 12 Essential Math
Evening Classes – Second Semester – January 29, 2018 – June 7, 2018
Time / Days / Class /
6:00 p.m. – 9:00 p.m. / Monday & Wednesday / Grade 12 Pre-calculus
6:00 p.m. – 9:00 p.m. / Monday & Wednesday / Grade 12 Chemistry
6:00 p.m. – 9:00 p.m. / Monday & Wednesday / Grade 12 Computers / Office Administration
6:00 p.m. – 9:00 p.m. / Tuesday & Thursday / Grade 12 English Language Arts Transactional
6:00 p.m. – 9:00 p.m. / Tuesday and Thursday / Grade 12 Physics
6:00 p.m. – 9:00 p.m. / Tuesday & Thursday / Grade 12 Applied Math
CrossRoads Learning CentrePage 1June, 2017