Language Training Centre

Student Information

Personal Information

Family Name: Click here to enter text Given Names(s): Click here to enter text

Mailing Address: Apartment Number Street Number and Name	City

Province	Postal Code

Home Phone: Click here to enter Other phone: Click here to enter text.

Email: Click here to enter

Date of Birth: Year/ Month /Day CLB levels: L Listening / S Speaking / R Reading / W Writing

Marital Status: Choose an item. ☐ Male ☐ Female

Is your husband/wife	☐ attending school?	Where? Click here to enter

☐ working?	Where? Click here to enter text.

Do you have children? ☐ Yes ☐ No How many? Choose an item. Age(s) Click here to enter

Country of Origin: Click here to enter Language(s) Spoken: Click here to enter text.

How long have you been a resident of Manitoba? Years: Click here to enter Months: Click here to enter

Are you currently working? ☐ Yes ☐ No Number of hours per week: Click here to enter

Do you have any health concerns you would like to share with us? ☐ Yes ☐ No

If yes, please explain: (For example – Diabetes) Click here to enter

Do you take any medications that we should know about? Click here to enter

In case of an emergency at school, who can we call?

Contact: Family Name Given Name(s) Telephone Number

Education

How many total years of education do you have? Click here to enter years

Did you attend a college or university in your country?	☐ Yes	☐ No

Name of College or University: Click here to enter

City and country: Click here to enter

Name of degree or diploma (What did you study?): Click here to enter

Did you complete your studies and graduate?	☐ Yes	☐ No

Past Work Experience

What was your main job/occupation in your country? Click here to enter

How many years did you work in your occupation? Click here to enter

Have you worked in Canada?	☐ Yes	☐ No

If yes, what did you do? Click here to enter

Do you have a counsellor at/or have you ever accessed services at:

☐ Manitoba Employment/Canada Employment	☐ Workers’ Compensation

☐ Employment and Income Assistance

Counsellor: Click here to enter counsellor’s name Click here to enter counsellor’s phone number

Have you ever gone to/or accessed services at:

☐ International Centre

☐ Manitoba Start

☐ Other Click here to enter

Employment and Education Goals

What are your goals/plans for study or work in Canada?

Click here to enter text.

I give my permission for the information provided in this application to be shared with my teachers, the Language Training Centre administrative staff, and the International Education Office where applicable. As well, I agree that information about my progress can be shared with teachers and with program funders as required.

Signature: __________________________	Date: _______________________