Education Program Sign-up

1
Name* This field is required.
First Name
Last Name
2
School Email* This field is required.
3
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Street Address
Street Address Line 2
City
Province
Postal Code
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4
Language Preference* This field is required.
English
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5
Phone Number
Area Code
Phone Number
6
Name of College or University* This field is required.
7
Program or Area of Study
8
Upload a picture of your current Student/Faculty ID card* This field is required.
9
Membership ID
10
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Yes
11
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