Test Survey Page NOTE: All fields are mandatory. Incomplete applications will impact your eligibility into the program. Classes will commence January 26, 2018 and end on March 30, 2018 Name:* First Last Please select the course of interest:*Letters from Winters of Yesteryear (Fridays 2:30-4:30 PM)Leadership studies (Fridays 12:00-2:00 PM)Psychology of Performance (Fridays 9:30-11:30 AM) Address:* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Temporary Address or Contact:If you have no permanent address, please list the agency where you are staying, or where you can be contacted, or by whom. Phone (Day):*Phone (Night):*Email:* Preferred Method of Contact:*EmailCanada PostBoth Gender:*MaleFemale Date of birth: MM DD YYYY EDUCATION Highest level of education completed (Please indicate the grade or course you took):GradeCollegeUniversityIf you did not complete your schooling, please explain why?: How do you plan on attending both class and discussion groups? (This does not determine your eligibility into the program)Monthly bus passBus ticketsNeed assistance with attending DU programmingWould you like library access for the University of Ottawa?YesNoWould you like a computer and/or wireless access at the University of Ottawa? (You will need an e-mail address to have access):YesNoAre you comfortable speaking and writing in English?:YesNo Can you commit to 5 - 7 hours per week of study? This includes attending 2 hours of lecture, 1.5 hours of discussion group time and completing the assigned readings.*YesNo If possible, would you prefer to be in a discussion group with individuals of your same gender:*YesNo preference Will you attend the meals provided prior to the discussion groups?*YesNo Please indicate any food allergies (and/or if you require a vegetarian meal): How did you hear about Discovery University? Can we tell others that you have applied for this course?*YesNo Is this your first time applying to Discovery University?*YesNo If not, how many Discovery University courses have you taken? For statistical purposes, we are collecting data on our students' sources of income. If you are willing to share this information, please state your source of income in the space provided. (e.g. Ontario Works, ODSP, pension, etc.). Source of Income:* WRITTEN STATEMENT Please write one or two paragraphs explaining why you would like to be a student in the Fall 2017 term. Please note that this writing will be used to evaluate your literacy level as well your enthusiasm for the course material. Both first time and repeat students are required to submit a written statement. If interested in the Digital Photography class, please state whether you have a camera of your own or would require a loan of equipment.Please use the space below for your written statement:*PROFESSIONAL REFERENCE For new students, you must submit a professional reference. References must be a professional who knows you well, such as a counselor, agency supervisor, clergy, doctor or case worker. We understand that this information gives us permission to speak with your reference. Please let this person know that you have given us their name and permission to ask about you.Reference name:Reference Phone #:Reference Fax #:Reference's relationship to you:Completed applications must be returned no later than Friday January 19, 2018 to: Discovery University, The Ottawa Mission, 35 Waller St. Ottawa, ON K1N 7G4 Tel: 613-914-4575 Fax: 613-234-2813The organizations involved in planning this program are committed to protecting your privacy and maintaining your confidentiality. By signing you are giving consent to allow The Ottawa Mission to use the information collected, ie. your gender, age, education, source of income, and interests for statistical and evaluation purposes only. Any information that reveals parts of your identity will NOT be used.