Qualico Bridge to Success Program - Application and Info Form

First Name:
Last Name:
Student Number (if known):
I am interested in the following Field of Study:
Mailing Address:

Province or Territory:

Postal Code:
Home Phone:
Cell Phone/Personal Phone:
I am:
Name of Home Community:
I would prefer to attend a Summer Boot Camp on:
I am interested in registering in ARTS 1110 (Introduction to University):
I feel I could benefit from help with my reading skills:
Please list any other activities or learning opportunities you would be interested in:
Please select one of the following:
Where did you hear about the Qualico Bridge to Success Program?
Other (if not listed above):

Thank you for your interest. The program facilitator, Carla, will email you soon with more information!

This personal information is being collected under the authority of the University of Manitoba Act and will be used for Indigenous Student Centre Program Management. It will not be used or disclosed for other purposes, unless permitted by the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection of your personal information, contact the Access and Privacy Office (204-474-9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB R3T 2N2.

If you are having issues submitting this form, please contact the program facilitator directly at Carla.Loewen@umanitoba.ca.