Name *

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Date of Graduation *

MM

DD

YYYY

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As required by the provisions of the Personal Information Protection Act, S.A. 2003, c.P-6.5 and the Freedom of Information and Protection of Privacy Act, R.S.A. 2000, c.F-25 our Society is required to obtain your consent for the collection, use and disclosure of any of your personal information. As a means of updating our donors and general public, our Society may periodically publish the name and personal photograph of the individual who received the scholarship, along with the high school they graduated from, the institution they are currently attending.

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