Application for CPISRA Introductory Course

We are collecting your personal information under the authority of the Colleges Act (RSA 2000, Chapter c-19), which mandates the provision of programs and services. We ask for this information to determine your eligibility for training and contracted services, and for research and statistical purposes. If you have any questions about the collection of this information, you may contact the Registrar's Office at (780) 623 5513.

Contact Information
*First Name:	*Last Name:


*Mailing Address (Box Number or Street Address):	*City/Town:

Province/State:	*Country:

*Zip or Postal Code:

*Email Address:

*Home Telephone:

Work Telephone:

Alternate Telephone:


*Date of Birth:
Day:	Month:	Year:

*Gender:
Male Female

*Credit Card Holder Name:

Your Profession: (Check one or more boxes and provide a brief description)

Doctor Physiotherapist Sports Technician

How did you find out about this program?

Word of Mouth National Organization CPISRA Website

Other Website/Link Other (provide a description)

CONSENT TO RELEASE INFORMATION

I authorize Portage College to disclose relevant personal information about me collected on this form, as required:

to the Department of Learning to maintain enrolment and statistical reporting; and
to its contracted agents for the purposes of confirming my enrolment and to determine my eligibility for these services.

*Please check the box if you agree with the statements above and approve that the information you've provided is correct.