Georgian College

ABORIGINAL SERVICES INFORMATION FORM If you are a student of Aboriginal ancestry (Status, Métis, Inuit or Non-status), please let us know so that we can hear your ideas for services and programs and inform you about upcoming programs and workshops. PLEASE FILL OUT THIS FORM AND RETURN IT BY MAIL OR EMAIL TO: Kathy Marsden, Getsijig (Native Education Counsellor) Aboriginal Resource Centre, Room M137 Georgian College, One Georgian Drive, Barrie, ON, L4M 3X9 kathy.marsden@georgiancollege.ca Student number _______________________________________ Program of study ____________________________________________ Year of study ____________________________ Semester____________________________Campus ______________________________ mFull-time mPart-time mApprenticeship mCertificate mDiploma mDegree Last name _________________________________________________________________________________________________________ First name and middle initial _________________________________________________________________________________________ Current street address ______________________________________________________________________________________________ City __________________________________________________Postal code __________________________________________________ Phone ________________________________________________Cell phone ___________________________________________________ Email address ______________________________________________________________________________________________________ Permanent street address____________________________________________________________________________________________ City __________________________________________________Postal code __________________________________________________ Permanent telephone __________________________________Emergency phone ____________________________________________ Home community (First Nation) ______________________________________________________________________________________ mStatus mMétis mInuit mNon-Status FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT: The information in this form is collected under the legal authority of the Ontario Colleges of Applied Arts and Technology Act, 2002, c. 8, Sched. F. This information is used for internal administrative and statistical purposes by Georgian College and may be shared with the Ministries/Agencies of the Government of Ontario and/or the Government of Canada. Information will also to be shared with third-party service providers who are retained by the college to provide services to students or act as agents of the college (working in accordance with privacy guidelines). By consenting, you are authorizing Georgian to use your personal information for processing your application, acceptance or registration as well as research, taxation, student insurance or funding purposes. I have read the above statement and hereby consent to the use of the following personal information for purposes stated in the above paragraph. Signature _____________________________________________ Date ________________________________________________________ IF YOU HAVE ANY QUESTIONS ABOUT SERVICES AND PROGRAMS, OR ABOUT THIS FORM, PLEASE CONTACT US. Barrie Campus ...............................................................................................................................................705.728.1968, ext. 1316 Midland Campus ...........................................................................................................................................705.526.5124, ext. 3742 Muskoka Campus (Bracebridge) ...................................................................................................................705.728.1968, ext. 1316 Orangeville Campus ......................................................................................................................................705.728.1968, ext. 1316 Orillia Campus ...............................................................................................................................................705.325.2740, ext. 3023 Owen Sound Campus ...................................................................................................................................519.376.0840, ext. 2096 South Georgian Bay Campus (Collingwood) ................................................................................................705.728.1968, ext. 1316 13

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