Fillable Part-Time Program Application (The Michener Institute of Education at UHN)

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Part-Time Program Application (The Michener Institute of Education at UHN)

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Part-Time Program Application
Registrar’s Office - Admissions
222 St. Patrick Street Toronto, ON M5T 1V4
regoffice@michener.ca │ 1 (416) 596-3117 or 1 (800) 387-9066
Part-Time Program Application Form (1) 2020-05-29
Date Received
Office Use Only
PERSONAL INFORMATION
LAST NAME
FIRST NAME
MIDDLE NAME
STUDENT ID # (former students)
DATE OF BIRTH (MM/DD/YYYY)
________ /________ /___________
GENDER: [ ] Female [ ] Male [ ] Other
COUNTRY OF CITIZENSHIPSHIP
[ ] Canadian [ ] Other _________________________________
LANGUAGE (FIRST)
[ ] English [ ] French [ ] Other: ______________________
VISA STATUS
[ ] International Student [ ] International Student with Study Permit [ ] Permanent Resident [ ] Protected Person/Refugee
CONTACT INFORMATION Tick this box if you would like to update the address on file with the address below.
ADDRESS
PROVINCE
POSTAL CODE
TELEPHONE
(_______) ___________ -__________________
EMAIL ADDRESS
PROGRAM SELECTION - $35.00 Application Fee - One Form Per Program Choice ($95.00 for International Applicants)
PROGRAMS (must apply before registering for courses)
Bridging Programs
PROGRAMS (can complete courses before applying to program)
PLANNED START DATE (MM/YYYY): ______ /________
APPLICATION FEE - PAYMENT METHOD
Cash (in person only)
Debit (in person only)
Credit Card (Visa, MC, AMEX)
Money Order (or Certified Cheque)
Card #: ________________________________________ Expiry Date: _________________________
Enter Numbers Only – No Spaces
MM/YY
Name: _________________________________________ Signature: ___________________________
PRINT CLEARLY
AUTHORIZATION AND DECLARATION
I understand that if any information in my application is determined to be false or misleading, concealed or withheld, my application may be invalidated and this could
result in its immediate rejection or in the revocation of an offer of admission or registration at The Michener Institute of Education at UHN. I, the undersigned, declare
that all application information and all supporting documentation are truthful, complete and correct.
Student Signature
: ____________________________________________________________
Date: _________________
OFFICE USE ONLY:
Processed By
: ___________________________________________________________________
Registrar’s Office Staff Name
Date
________________________
The information on this form is collected under the authority of the Michener Institute of Education at UHN and will be protected and used in compliance
with the Ontario Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. F.31. Student information held by the Michener Institute of
Education at UHN may be used for administrative and statistical purposes of the Institute and/or the ministries and agencies of the Government of Ontario
and the Government of Canada.
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Part-Time Program Application (The Michener Institute of Education at UHN)

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Completed 10 February 2021

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