Student for Company Program Registration - JA South Western Ontario

Student for Company Program Registration
Title 1:		*
First Name:		*
Last Name:		*
Preferred Email:		*
Home Phone:		*
Home Country:		*
Home Mailing Address:		*
Home City:		*
Home Province:		*
Home Postal Code:		*
Personal agreement to school year responsibilities:		*
Student parent or guardian name:		*
Student parent or guardian phone number:		*
Student grade:		*
Student # of prior years attending Company Program:		*
School name:		*
Personal emergency contact name:		*
Personal emergency contact phone number:		*
Personal notes / comments:

Account Information
Username:		*
Password:		*
12 characters or more.
Confirm Password:		*

By submitting this Student for Company Program Registration Form, I understand and agree to the responsibilities of participating in JA programs. These responsibilities include:
- I understand that I will be placed into a company and I agree to work with that team for the program year
- To respect my fellow Company Program team members and partner with them in the spirit of learning / growth
- To communicate with JA Company Program advisor(s) with any questions/comments/concerns
- To participate fully and have fun!

• Volunteer

• Educator

• Student