Application Form
Shiatsu School of Canada 547
College St. Toronto, Ontario M6G 1A9
Telephone: (416) 323-1818 or Toll free: (800) 263-1703
(USA & Canada only)
Program
applying to: ____________________________________
Preferred
start date: ____________________________________
Personal Data: (Please Print)
Name: ________________________________________ /
________________________ / ____
(last) (first)
(initial)
date
of birth: _____ / _____ / _____
age:
_____
S.I.N. _______ / _______ / _______
day mth
yr
address: _________________________________________________________________
street
__________________________________ _______________________________
___________________
city
province
Postal Code
Email address: _____________________________________________
phone:
(Business) ____________________________ (home)
_______________________________
NEXT OF KIN: ___________________________________ relationship:
_______________________
ADDRESS:
____________________________________________________________________________
_____________________________________________________________________________________
FAMILY PHYSICIAN:
____________________________________________________________________
name
______________________________________________________________________________________
address
Illnesses Within the Past Year:
___________ from _______
to _______
PRESENT OCCUPATION:
_____________________________________________________________________________________
Company Name / Location /
Phone
________________________________________________________________
Position/Title
Duration
PAST WORK EXPERIENCE:
_____________________________________________________________________________________
Company Name / Location /
Phone
________________________________________________________________
Position/Title
Duration
POST- SECONDARY EDUCATIONAL:
School Name /
Location
Program / Course
Length of Study Year Graduated
____________________________________
____________________ ______________ _____________
____________________________________
____________________ ______________ _____________
TUITION PAYMENT PLANS:
I plan to pay: (check one)
In full Yes ____ No ____
In Installments:
Yes___ No ____
Note: Payments can
be made by cash,
certified cheque or money order, and in Canadian funds only.
There is a late charge
of $10 per day ($50.00 per week), on overdue accounts.
DOCUMENTATION
REQUIRED:
The following documents must accompany your application. Check if
included in your application. If not included, indicate date it will be
available.
- complete application
form ___
- application fee of $10 ___
- proof of high school diploma or GED (General
Educational Development Test) and transcripts* ___
- transcripts from other relevant programs of
study ___
- completed medical
letter from your family physician indicating that you are in good
physical and general health, that you are free from communicable diseases
and your tuberculosis status within the last year ___
- copy of your birth certificate ___ (shiatsu
diploma program only)
- photo identification (e.g. driver's license,
passport, age of majority card) ___ (shiatsu diploma program only)
- copy of your Social Insurance Number card ___
(shiatsu diploma program only)
NOTE: The school reserves the
right to cancel or change start dates of program if there is insufficient
enrolment. Should the program be cancelled, the applicant will receive a
complete refund for their registration fees and/or tuition.