Laurentian Initiative for Transition (LIFT)
Application 2017
Name:
Your answer
Preferred Language:
Language of Study
Gender:
Address:
Your answer
City:
Your answer
Province:
Your answer
Postal Code:
Your answer
Telephone:
Your answer
Cellphone:
Your answer
Email:
Your answer
Alternate Email:
Your answer
Do you have any allergies or dietary restrictions? if yes, please specify.
Your answer
Emergency Contact Name and Relationship:
Your answer
Emergency Contact Number:
Your answer
Information Regarding Disability and/or Medical Condition
All information provided will be kept confidential.
Please select an option that best describes your disability and/or medical condition:
Do you have documentation of your disability and/or medical condition?
Do you have a psycho-educational assessment?
If you answered yes above, what is the date of the assessment report?
MM
/
DD
/
YYYY
Residence Information
Will you be living on campus in your first year?
If so, which residence will you be staying in?
Why LIFT?
We would like to learn more about you and why you want to take advantage of our program.
In your own words, tell us why you would like to participate in the LIFT program.
Your answer
In your own words, tell us how your disability or medical condition effects your learning.
Your answer
What kind of help and/or support did you receive in highschool? (E.g. Assitive technology, learning strategies, testing accommodations, counselling)
Your answer
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