Grand Erie Learning Alternatives
(519) 753-6079
Deadline: June 25, 2021 – email to:
Legal Last Name
Legal First Name
Usual Name
Male Female Other
Present School Name and School Board Name
Student Email (used in school)
Parent Email
Date of Birth (MM/DD/YYYY)
Address (No. & Street, City/Town, Province, Postal Code)
Current Grade
Home Phone
Parent/Guardian #1 Name & Phone
Emergency Contact Name
Canadian Citizen?
(If no, please submit immigration documents)
First Nations Status?
Yes No
New Credit or Six Nations
Yes No
First Choice Course
Note: *LIMIT OF 1 CREDIT TO BE EARNED* If registering for both Civics and Careers (.5 credit each), please place
both courses in First Choice section. If you have an IEP, please ask your school to scan it to the email above.
Secondary students must consult their counsellor to ensure proper course code and pathway has been selected.
Parent/Guardian signature (for all students under age 18 years):
Signatures: Counsellor (secondary) or Principal (elementary)
Student Signature:
July 6, 2021 to July 30, 2021