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Esquimalt High School 4C Challenge Program Application: Part One
Please remember to fill out the Parent/Guardian and Student Consent Form and the Student Interest and Achievement Survey.
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* Indicates required question
Surname
*
Your answer
First Name
*
Your answer
Date of Birth
*
YEAR/MONTH/DAY e.g. 1997/06/22
Your answer
Present School:
*
Your answer
Gender:
*
Male
Female
Current Grade:
*
8
9
10
11
French Immersion:
*
Yes
No
Contact/TAG Teacher:
*
Your answer
Parent/Guardian Contact Name(s):
*
(Mr. Mrs. Ms.)
Your answer
Address:
*
Your answer
Postal Code
*
Your answer
Home Phone:
*
Your answer
Work Phone:
Your answer
Cell Phone:
Your answer
Parent/Guardian Email Address:
Your answer
Mt Doug 2nd choice?
*
Yes
No
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