Powell River International Education

POWELL RIVER INTERNATIONAL STUDENT APPLICATION ONLINE FORM
For a printable version you can mail or fax to us, please click here.

Family Name: Given Name/English Name:

Address:

Birthdate: Day Month Female Male

Mother's Name: Father's Name:

Mother's Birthdate (dd/mm/yyyy): Father's Birthdate (dd/mm/yyyy):

Telephone: E-mail:

Education:
1. School: Dates Attended: Last Grade Completed:
2. School: Dates Attended: Last Grade Completed:

I wish to attend:
Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12

For a period of: 5 Months 1 Year 2 Years Longer

I wish to graduate from a Canadian High School: Yes No
I wish to attend a Canadian University in the future: Yes No

I wish to begin my Canadian studies: (please enter month and year)

Activities/Sports/Subjects I Enjoy:

Others:

I have the following Allergies/Health Concerns:

I smoke: I do NOT smoke:

Homestay Preferences:

Emergency Contact: Relationship:

Contact's Address:

Contact's Phone: Fax: Email: