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 (YYYY-MM-DD)

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)

Alberta Student Number(not MHC Student ID #)

Citizenship Status (*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.

Canadian

Permanent Resident

Protected Person*

Alberta Residency: 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.)

Yes

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

Student ID Number(not MHC Student ID #)

Address of Institution

City/Town

Province/State

Country

Postal/Zip Code

Program of Study

Year of Program

Program of Study Start Date (MM-YYYY)

Anticipated Date of Completion (MM-YYYY)

Program Length (specify months or years)

Level of Study

Undergraduate

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

Expected Credential (select one)

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.

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Laurence Decore Award for Student Leadership (value $1000)