-
- For which school session are you applying?**
-
- If your desired session is unavailable, are you open to alternate dates?*
- CANOPI students must be able to communicate in English. Please indicate if you speak, read and write English.*
-
-
-
-
-
- Date of Birth*
-
-
-
-
-
-
- Do you have a valid passport?*
-
-
- Do You Have Children?*
-
-
-
-
-
-
-
- Which of these issues have you struggled with, past or present?*
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Are You Currently Employed?*
-
- What are some of your practical skills, talents, and abilities? (Select all that apply)*
-
-
-
-
-
-
-
-
-
-
-
-
- Which, if any, of these substances do you use?*
-
- Are you currently taking any medications? (Please provide details below.)*
- Do you have any physical handicaps or health conditions which may require special attention? (Please provide details below.)*
- Have you ever been treated for emotional or psychiatric instability? (Depression, anxiety, schizophrenia, etc.) (Please provide details below.)*
- Have you ever experienced any of the following? (Check all that Apply) (Please provide details below.)*
- Have you had any surgeries in the last 10 years? (Please provide details below.)*
- Do you have any food allergies? (Please provide details below.)*
- Are you allergic to any of the following? (Please provide details below.)*
-
-
-
- Are you from Costa Rica?*
-
-
-
-
-
-
-
-
-
- Date Signed*
-
- Should be Empty: