Last Name

First Name

Previous Last Name (if applicable)

Apartment or Box Number

Street Address (add direction, e.g. S, NW, SE, if applicable)

City/Town

Province/State

Country

Postal/Zip Code

Mobile Number (format: 999-999-9999)

Alternate Number (format: 999-999-9999)

Email Address

Birthdate (DD-MM-YYYY)

Gender (Choose X if you do not identify as male or female, or choose to self-identify as X)

Male

Female

Indigenous Status (select one)Providing personal information on Indigenous students will help measure the effectiveness of student financial assistance programs in relation to Indigenous students and to research programs and services to improve student success rates. If you wish to declare your Indigenous heritage, please select the option above that applies to you. NOTE: This is mandatory for awards which require Indigenous status as part of the eligibility, voluntary otherwise.

Citizenship Status (select one)*If you are a Protected Person, including Convention Refugee, you must submit: • A copy of your Social Insurance Number card AND • A copy of one of the following: - Notice of Decision, or - Verification of Status Document (VOS) The documentation must be valid on your Program of Study Start Date.

Alberta Residency:

Yes

Did you or one of your parents or legal guardian live in Alberta for at least 12 consecutive months immediately prior to commencing post-secondary studies? (Do not include time attending post-secondary studies or vacations.)

If you answered no to Alberta Residency, was your spouse/partner an Alberta resident immediately prior to you commencing post-secondary studies?

Yes

Post-Secondary Institution Name

Alberta Student Number (not MHC ID#)

MHC Student ID

Address

City/Town

Prov/State

Country

Postal/Zip Code

Program of Study

Collaborative Program

Yes

Level of Study: (check one)

Undergraduate

Professional Program (e.g. medicine, veterinary medicine, optometry, etc.)

Program of Study Start Date (MM-YYYY)

Program Length (specify months or years)

Current Year of Study

Expected Credential (e.g. upgrading, transfer, degree, diploma, certificate, other)

I have read and understand the instructions, and declare that:

All information provided is true and complete and I understand it is subject to verification.

I will immediately notify Medicine Hat College if there are any changes to the information I have provided in this application.

I authorize my post-secondary institution to disclose information collected on this application form, my program of study and any award details (if I am selected) to Alberta Student Aid, and I authorize Alberta Student Aid to collect this information from the post-secondary institution for the purposes of administering the Louise McKinney Post-Secondary Scholarship under the Heritage Scholarship Act, including confirming my eligibility and suitability for this award, for program evaluation and for research and statistical analysis.

Please check this box

This website does not support Internet Explorer

Alberta Athletic Award