Applicant Information

Salutation:
First Name:*
Last Name:*
E-Mail:*
Home Phone:*
Mobile:*
English as a Second Language?*
First Language*
Gender*
Social Insurance Number (For Canadian Resident Tax Form Reasons Only)
Birth Date:*
Do you hold a current Nursing Licence?
Nursing License Number
Nursing License Province

Please upload and attach:

  • Nursing License if applicable
  • if under the age of 21, upload your highschool diploma

Documents
  
Country:*

Address in Canada

Address1:
Address2:
City:
Province/State:
Postal/ZipCode:

Emergency Contact/Next of Kin

Emergency Contact: Full name:*
Emergency Contact: Relationship:*
Emergency Contact: Phone #:*
Emergency Contact: Address:*

Program Information

Program of Interest?*

What is your desired start Year and Month.
We will confirm your actual start date based on the registration process completion.

Desired Start Date
How did you hear about us?*
Please Specify:*

Additional Information

Name Of High School
Location of High School:
High School Grad Date
Higest Level of Education*
By submitting this form, I agree that Atlantic College of Applied Health Sciences may call, text and/or email me about their educational services