REGISTRATION FORM

	Sir Winston Churchill Success Cooperative Education Registration Form (Please attach copy of Credit Counseling Summary and I.E.P.)
Student Name
Home Address
Home/Cell
email Address
Parent/Guardian
Home/Cell/Business
email Address
Social Insurance Number
Health Insurance Number
Doctor Contact Info
Career Choices	1.
	2.
Placement Information	Placement:
	Contact Person:
	Business Address:
	Business/Cell:
	email Address:
	Website:
	1 Credit	2 Credit	3 Credit	4 Credit	AM or PM
OYAP