Portage College Online Application

We are collecting your personal information under the authority of the Colleges Act (RSA 2000, Chapter F-25) which mandates the provision of programs and services. We ask for this information to determine your eligibility for training and applicable services, and for research and statistical purposes. If you have any questions about the collection, use and/or disclosure of this information, you may contact the Registrar's Office at (780) 623-5580.



* Program Applied For: * Full/Part Time: * Location:
Full time Part time

September/January Term: Year:
September Term January Term

Is this an eCampusAlberta offering?
Yes No If yes, eCampusAlberta Partner location: 


* How did you find out about this program? (Check ONE box only)
Newspaper Agency Referral Television Calendar/Brochure
College Website Word of Mouth Community Info Fair Other Website/Link
Career Day High School Visit High School Counselor Open House
Radio Other


Personal Information

* First Name: * Last Name:
Middle Name: Maiden Name (if applicable):
Other Names By Which I Am Known: Student Identification Number:
Country of Birth: Language First Spoken:


Citizen Status:       Canadian Citizen       Permanent Resident       Student Visa       Other Visa

Citizenship Date of Entry: Day:   Month:   Year:  

If you wish to declare that you are an Aboriginal person, please specify:
Status Indian/First Nations Non-Status Indian/First Nations Metis Inuit 		   
     


* Gender: * Date of Birth: Alberta Education ID Number:
Male Female


Marital Status: Single                     Married / Common Law               Other
In the past year, I was: Student Employed Other
In the past year, I have lived:                 Alberta Another Province Outside Canada


Do you have any disabilities that require consideration?
Learning Disablity Physical Disablity Emotional/Mental Health Medical Illness/Condition Other

If Other, please describe:


Contact Information

Mailing Address (Box Number or Street Address): City/Town:
Province: Country:
Postal Code: Home Community:
Email Address:
Home Tel: Work Tel: Alt Tel:


Education History

Name of Last Public/Separate School Attended: Location:
Last Grade Completed: Last Attended:


Have you previously applied to Portage College (formerly AVC Lac La Biche)? If yes, what year?
Yes No


Highest Education Achieved:
Elementary Public College Private College Vocational College
High school University Technical Institute Other


Name of Last Post-Secondary Institution Attended: Location:
Year Last Attended:




Consent To Release Information

I authorize Portage College to disclose relevant personal information about me collected on this form, as required:
  • to its contracted agents or societies for the purpose of confirming my enrollment status and to determine my eligibility for contracted services
  • to Alberta Learning to maintain enrollment and statistical reporting , and to obtain my statement of marks or student identification number.


* I hereby consent to the above conditions:     Yes     No