Please Note: You will be contacted with your student ID and payment information once your registration has been started. Registration is not complete until payment has been received. Student Information Name Given Given Middle name(s) Middle name(s) Family Family Previous/Maiden Name(s) (if applicable) Gender Male Female Date of Birth (mandatory) Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018 Alberta Teaching Certificate Number (Mandatory to register in ELQS 001 and ELQS 002) Student ID (if applicable) Mailing Address City/Town Province/State Postal Code/Zip Code Phone Number Email Address Teacher Information I am a teacher education student I am a K-12 teacher Other Registration Information Where are you earning your Bachelor of Education? Other description: Extended Learning Course ELQS 001- Becoming a Transformative Principal July 8-12, 2019 (On Campus) ELQS 001- Fall 2019 – Blended Online ELQS 002- Winter 2020- Blended Online CDPD 400 (Spring, 2019) Questions or Comments? I certify that the information provided is true and complete in all respects and understand that failure to provide complete and true information may result in penalties. I understand that I will be bound by the regulations of Ambrose University as listed in the Academic Calendar. Student Signature I agree Ambrose University is committed to safeguarding the personal information entrusted to us. We manage your personal information in accordance with Alberta’s Personal Information Protection Act and other applicable laws. Information collected in this form may be used to contact you regarding programs and services. It will form part of your record as an applicant, student, and alumnus and may be disclosed to academic and administrative units. All information is considered confidential and will be used and disclosed in accordance with privacy legislation. For more information regarding the collection or use of this information, please contact the Privacy Compliance Officer (403-410-2000 or e-mail email@example.com).