SVAE Registration Form 533 A St. Anne’s Road, Winnipeg, MB, R2M 3E8 PH (204) 254-1618 ext. 200 or 206; FAX (204)255-2129 in partnership with SVAE Registration Form Step 1 of 7 14% Student InformationName* First Middle Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email* Enter Email Confirm Email Cell PhoneHome PhoneDate of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleX Statistical InformationHow many years has it been since you attended high school?*5 or less6 - 1011 - 20More than 20UndeclaredWhat is the last grade you have completed?*Less than Grade 8Grade 8 or 9Grade 10 or 11General Education Diploma12 MB / Other Current Employment Status:Current Employment Status* Employed Part-Time Employed Full-Time Voluntarily Unemployed Disability Insurance Income Assistance Employment Insurance Worker's Comp Band Funded Not Employed (Actively seeking work) Are you a single parent of children under the age of 6?*YesNo Additional InformationIs English your first Language?*YesNoDo you speak English as an additional language (non-Aboriginal)?*YesNoDo you speak English as an additional language (Aboriginal)?*YesNoAncestry* First Nation Metis Inuit Visible Minority Other Do you hold a professional degree from a foreign country?*YesNoHave you completed high school credits at other adult learning centers?*YesNoHave you ever participated in literacy upgrading through another program?*YesNoHave you ever participated in EDGE Literacy program?*YesNoHave you ever participated in EDGE Bridge program?*YesNoHave you had any industry training such as apprenticeship?*YesNoHave you completed any post-secondary certificates/diplomas/degrees?*YesNoLegal: Do you have a criminal record?*YesNoHow did you hear about St. Vital Adult Education Center?* Friends Family Co-workers Employer Newspaper Other Medical InformationDoctor:Dr. Office PhoneAllergiesMedical ConditionMedicationEmergency Contact Name* First Last Emergency Contact Phone* Student Receiving Income Assistance (EIA)If you are not receiving assistance please click 'next' belowAre you currently receiving Income Assistance?*YesNoWorker's Name First Last Worker's PhoneOffice Location Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Case Number FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT“This personal information is being collected under the authority of the Manitoba Public Schools Act and the Education Administration Act. It will be used and disclosed for the purpose of determining learner demographics for statistical analysis including research and evaluation, program planning and accountability, funding applications and the completion of periodic statistical reports as required by provincial authorities. The Protection of Privacy provisions of the freedom of Information and Protection of Privacy Act protect this personal information. If you have any questions about the collection of personal information contact: St. Vital Adult Education Center, 533 A St. Anne’s Road, Winnipeg, MB, Ph. (204) 254-1618.”DECLARATION – I certify that the information provided by me is true and to the best of my knowledge.* I agree that St Vital Adult Centre may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, graduation and Web content.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.