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Last name*
Given name*
Other name*
Date of birth dd/mm/yy*
/Month /DayYearDate
Citizenship*
Gender*
FemaleMaleOther
Home Address*
City*
State/Province*
Country*
Postal Code*
ID/Passport No.*
Email*
example@example.com
Phone*
–Country Code eg 234 –Area Code eg 803Phone Number last 7 digits
Mother’s Name*
Father’s Name*
Mother’s Phone*
–Country Code eg 234 –Area Code eg 803Phone Number last 7 digits
Father’s Phone*
–Country Code eg 234 –Area Code eg 803Phone Number last 7 digits
Mother’s Email*
example@example.com
Father’s Email*
example@example.com
Grade Applied For (Tick one)*
9101112
Previous Schools Attended*
Dates Attended*
/Month /DayYearDate
English Language Proficiency Taken
IELTSTOEFLOther
Date of writing
/Month /DayYearDate
Future planned field of studies (mark all relevant)*
ScienceBusinessEngineeringLiberal Arts – Specify
By signing below you confirm that you read and agreed to abide by the code of conduct and terms and conditions of enrolment.
Student Signature*

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Date*
/Month /DayYearDate
Parent signature*

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Date*
/Month /DayYearDate
Please attach the following documents:
Upload Copy of passport – first 2 pages only*
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Upload Copies of all academic transcripts/report cards from Grade 9 onwards, in English*
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Upload Copy of IELTS of TOEFL test, if written within last two (2) years
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Contact Info

We are available to reply to your questions just give us a touch and we will take care of other things that can help us in communications.

Ontario Ministry of Education BSID # 668654
1-437-777-5880
info@brockacademy.ca

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