Canadian College Italy - The Renaissance School: Summer Academy Form

STUDENT INFORMATION

Prefix
First*
Middle
Last*
Suffix

Gender*

female male

Date of Birth* (mm/dd/yy)

Email Address*

Home Telephone*

Address*

Including Postal/Zip Code

Passport Number

Citizenship

Passport Expiry (mm/dd/yy)

Please list your First Course of Choice*

Enter Course Name and Code

Please list your Second Course of Choice *

Enter Course Name and Code

If taking Italian, previous knowledge of Italian?

yes no

MOTHER'S INFORMATION

Prefix
First*
Middle
Last*
Suffix

Email *

Occupation

Home Phone*

Mobile Phone*

Address*

Company Name

Business Phone

FATHER'S INFORMATION

Prefix
First*
Middle
Last*
Suffix

Email *

Occupation

Home Phone*

Mobile Phone*

Address (If Different From Above)

Company Name

Business Phone

GUARDIAN INFORMATION (If Applicable)

Prefix
First
Middle
Last
Suffix

Occupation

Home Phone

Mobile Phone

Address

Company Name

Business Phone

Summer Emergency Contact (Name)*

Home Phone*

Mobile Phone*

Send Invoices for Fees to *

mother father both guardian

Send School Reports and Correspondance to:*

mother father both guardian

Name & Address of Current School*

STUDENT PREFERENCES QUESTIONNAIRE*

Briefly describe your ideal roommate. Please list the name of your ideal roommate (if applicable)

Do you have any physical conditions that we should be aware of? (Ex. Food Allergies, Epilepsy, Diabetes) *

Do you have any restrictions with regard to physical activity?*

List any prescription medication you are currently taking*

List any drug allergies*

Please write a 250 word mini-essay explaining why you would like to attend CCI's Summer Academy (to be completed by applicant) *

Would you like to purchase Medical Insurance (add $60)*

Available to Canadian resident only

yes no

Would you like to purchase Program Cancellation Insurance (add $120)*

yes no

Please send a confirmation email to the address below*:

Please provide an email address where we can send a link to your current form.

Email Address :