MITT Adult Learning Centres

MITT Adult Learning Centres

2022/2023 APPLICATION FORM
Thank you for your interest in applying to the MITT Adult Learning Centres!

Formerly known as CrossRoads Learning Centre, Horizons Learning Cenres, Portage Learning and Literacy Centre (ALC and ALP programs), St. Norbert Adult Learning Centre, St. Vital Adult Learning Centre and UFCW Adult Learning Centre. The first step to register for classes is to give us a little bit of information about yourself and your academic needs. Please click on Next to get started!

STEP 1: CONTACT INFORMATION

Please provide us with your current contact information. This information will be used to contact you to select your classes, so please be sure that all information is correct.
All fields marked with * are required and must be filled.
Which location would you prefer to attend? *
Full Legal Name *

FIRST NAME MIDDLE NAME LEGAL LAST NAME
Previous Last Name
Maiden or previous last name
Apartment/House # and Street Name *
Apartment/House # and Street Name
City/Town *
City/Town
Province *
Province
Postal Code *
Postal Code
Cell Phone (Main Phone) *
Cell Phone
Alternate Phone Number
Alternate Phone Number
Email Address *
example@example.com
Date *

Month Day Year
MM-DD-YYYY
How old will you be on June 30, 2023? *
Age on June 30, 2023
Gender *

Male Female Other
What School Division do you currently live in? *
Please upload a copy of a government issued Birth Certificate. If you have a previous last name that you used, please also provide a copy of your Marriage Certificate or name change documentation. If you are unable to upload a document at this time, please bring these pieces of identification with you to your intake appointment.

Cancel of

STEP 6: EMERGENCY CONTACTS

Please provide the name of at least one emergency contact for when you are at school.
All fields marked with * are required and must be filled.
Emergency Contact # 1 - Name *
Contact #1 - First and Last Name
What is your relationship with this person? *
Contact #1 - Relathionship
Emergency Contact #1 - Phone Number *
Contact #1 - Phone Number
Emergency Contact #1 - Alternate Phone Number
Contact #1 - Alternate Phone Number
Emergency Contact #2 - Name
Contact #2 - First and Last Name
What is your relationship to this person?
Contact #2 - Relationship
Emergency Contact #2 - Phone Number
Contact #2 - Phone Number
Emergency Contact #2 - Alternate Number

FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT
The personal information that you provide is voluntary and confidential and will be used to assess your eligibility and suitability for our program. It is collected under the authority and regulations of the Manitoba Public Schools Act and the Educational Administration Act. The information will be used for the enhancement of educational programming, the completion of funding applications, and for the completion of periodic reports as required by the provincial authorities.
Declaration *

I consent to the verification of the information supplied in this application. I certify that the statements made by me are true and accurate to the best of my knowledge. By typing in my full name below, I am signing this application electronically. I agree that my electronic signature is the legal equivalent of my manual signature on this application.
Name

First Name Last Name
Date of Submission

Month Day Year
MM-DD-YYYY

Thank you for your interest in applying to the MITT Adult Learning Centres!