SLP Document Release Request

Name*

First NameLast Name

Name at time of Graduation (if different from above)

First NameLast Name

Year of Graduation*

Email*

example@example.com

Student Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Payment*

SLP Summary of Clinical Practice Hours form (Bodies outside Ontario)

$12.00CAD

Agency Summary of Clinical Practice Hours form (Bodies outside Ontario)

$12.00CAD

Self

$12.00CAD

Multi-Page Evidence and Summary Hours Form

$30.00CAD

Total

$0.00CAD

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Send the SLP Summary of Clinical Practice Hours Form to: *

Include the organization name and email address

Send the Agency Summary of Clinical Practice Hours form to:*

Include the organization name and email address. Students will submit the pre-filled form as required by the agency under separate cover to slp.clinicalaffairs@utoronto.ca for verification and signature. Students will include a report of any variance from the form required by the UofT SLP program.

Email to send to (if different from above)*

Multi-Page Evidence and Summary Hours Form*

Include the organization name and submission requirements (mail, email etc). Students will submit the pre-filled package of documents as required by the agency under separate cover to slp.clinicalaffairs@utoronto.ca for verification and signatures. Students will include a report along with the hours documentation of any variance from the form required by the UofT SLP program.