KSSEP Student Registration Form

Is this your first time participating in the KSSEP?*

Yes
No

Name*

First Last

Email Address*

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Band Number*

Date of Birth*

Gender*

Male
Female
Non-binary / third gender
Prefer not to say
Prefer to self describe

Social Insurance Number*

Medicare Number*

Name of Parent or Guardian*

First Last

I am a:*

Select the option which applies to you

High School Students - Grade entering

Post-Secondary Students - Major/field of study

I am included a copy of my acceptance letter from my school (Applicants who are entering a new CEGEP/university)

Yes
No

I am registered with the Kahnawake Education Center (Applicants who are entering or continuing in post-secondary studies)*

Yes
No

Date of Return to School*

If date is unknown, select the 1st of the return month

Name of the school you are attending*

What is your program of study or what grade will you be entering?*

Media Consent*

No
Yes (and I am 13+ years old)
Yes (and I am under 13)

I, the undersigned, hereby consent to the use of my photograph or likeness in any publication, videotape, pamphlet, or promotion by Tewatohnhi’saktha for promoting the Kahnawà:ke Summer Student Employment Program. I understand that I will not receive separate compensation or consideration from Tewatohnhi’saktha or anyone else for the permission granted in this Consent nor for the actual publication or use of my photograph or likeness. By signing this Consent, I understand I am releasing Tewatohnhi’saktha from any and all liability that may occur as a direct or indirect result of my photograph, the release of my identity, or the public relations materials, including but not limited to the use of any quotations.

Media Consent If Yes (and I am under 13)

Please fill in the contact info of the Parent or Guardian of the minor if media consent is given for a person under the age of 13

Supporting Documents

Please attach your CV and Letter of Acceptance (if applicable) in PDF format If you are unable to save as a PDF, or cannot submit your documents at this time for any other reason, you can also email them to katsistohkwiio.jacco@kedc.biz

Drop files here or

Accepted file types: pdf, Max. file size: 32 MB, Max. files: 4.

KSSEP Student Registration Form

KSSEP Student Registration Form

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