SHSM Certifications

Applicant's First Name* Applicant's Last Name* Home Phone* Mobile Phone Please identify your gender* Date of Birth*  /  / 

Adult Contact Email (acceptance pkg to come by email)* Street Address* City* Province* Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Postal Code (e.g A1A 1A1)*

Grade (as of June):* School Phone:* Full Name of School Board:* Signed Indication of Student Support:

School Name:* School Address:* School City:* School Province:* Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory School Postal Code (e.g A1A 1A1):*