VSOHA Program Application

Please complete all mandatory fields*

Program*
Start Date*
How did you hear about VSOHA?*
Please Specify Source:*

Personal Information

First Name:*
Last Name:*
Preferred Name:
Pronoun(s):
Mobile:*
Home Phone:
Secondary Phone Number:
Country:*
Province/State:*
City:*
Postal/ZipCode:*
Address1:*
Social Insurance Number (For Tax Purposes)
E-Mail:*
Payment Plan*

Background

Birth Date:*
Gender*:*
International Student?*
Study Permit:*
Immigration Status*
Citizenship*
Personal Education Number (if available)
Current Occupation:

Emergency Contact Information

Emergency Contact Name:*
Emergency Contact Primary Phone Number:*
Emergency Contact Secondary Phone Number:*

Application Questions

Health Evaluation

Do you take any medications regularly?*
List any medications taken regularly.
Do you have any physical limitations?*
Describe your physical limitations.
Are you currently receiving treatment for any reason?*
Describe the treatments you're currently receiving.
Do you have any allergies?*
List all of your allergies.
Any other illness, surgery, or injury?*
Describe other illness, surgery, or injury.

Completeness and Accuracy

Completeness and Accuracy*
I understand that by submitting this form, I agree to be contacted by VSOHA regarding our programs, using email, telephone, or text (SMS). My consent can be customized or withdrawn at any time.