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Registration Form - English as a Second Language
Continuing Education
Personal Development
English
Continuing Education - English as a Second Language
1. Course information | Renseignements du cours
Please Specify Your Course Selection | Veuillez choisir le cours désiré :
*
Please choose one / Veuillez en chosir un
999-002-07 ESL Conversation (Beginner)/Conversation d’ALS (Débutant) - Onsite Gatineau Campus/Campus Gatineau sur place - Winter/Hiver 2025
2025999-002-09 ESL Conversation (Intermediate)/Conversation d’ALS (Intermédiaire) - Onsite Gatineau Campus/Campus Gatineau sur place - Winter/Hiver 2025
2025999-002-11 ESL Conversation (Advanced)/Conversation d’ALS (Avancé) - ONLINE/EN LIGNE - Winter/Hiver 2025
Indicate the semester for which you are applying | Indiquez la session pour laquelle vous vous inscrivez :
*
Please choose one / Veuillez en chosir un
Fall / Automne
Winter / Hiver
Indicate the year for which you are applying | Indiquez l’année pour laquelle vous vous inscrivez :
*
Please choose one / Veuillez en chosir un
2025
I would be interested in taking this course online, if available | Je serais intéressé(e) par ce cours en ligne, s’il est disponible.
Yes / Oui
No / Non
2. Documents required | Documents requis : (In order for your application to be processed, all required documents must be submitted | Pour que votre inscription soit traitée, tous les documents requis doivent être soumis)
Valid Government Identification | Pièce d'identité officielle valide (Required for non-credit courses | Pièce d'identité officielle valide). Can be one of | Peut être l’un, soit :
a. Passport / Passeport
b. Drivers License / Permis de conduire
c. Health Card / Carte de santé
Please include a photo/scan of both the front and back of your proof of identification | Veuillez joindre une photo/numérisation recto verso de votre pièce d’identité
Proof of Identification Front | Pièce d’identité recto :
*
Proof of Identification Back | L’endos de la pièce d’identité :
*
3. Personal Information | Renseignements personnels
Family Name | Nom de famille:
*
First Name | Prénom :
*
Date of Birth | Date de naissance :
*
Gender | Sexe :
*
Male / Homme
Female / Femme
4. Permanent Address | Adresse civique (PLEASE NOTE: It is YOUR responsibility to notify us of any changes | VEUILLEZ NOTER : Il vous incombe de nous informer de toute modification)
Number | Numéro :
*
Street/Rural Route/P.O. Box | Rue/ Street/Route rurale/Casier postal :
*
Apartment | Appartement:
City/town | Ville :
*
Province:
*
Country | Pays :
*
Postal Code | Code postal (important):
*
Telephone | Téléphone primaire :
*
Secondary Telephone | Téléphone secondaire :
Email | Adresse courriel :
*
5. How did you hear about this training activity | Comment avez-vous eu connaissance de cette formation ? (maximum of 2 choices | maximum de 2 choix)
Please choose from below | Veuillez choisir parmi les options ci-dessous :
Newspapers / Journaux
Radio
Publisac
Friends / colleague / company - Amis / Collègues / Au travail
Social media of the educational institution / Média social de l’institution de formation
Other social media / Autres médias sociaux
Educational institution website / Site Web de l’institution de formation
Other websites / Autres site Web
Email / Educational institution newsletter - Courriel / Bulletin de l’institution de formation
Other emails / Newsletter - Autres courriels / Bulletins
Certificate and Signature | Certificat et signature
I certify that the information provided is correct | J'atteste que les renseignements fournis sont exacts.
If I am a Québec resident I also authorize Emploi-Québec and the training establishment offering the above measure to exchange the personal information necessary for the realization and the follow-up of my participation for the subsidy.
Signature:
Date:
Don't fill this field!
Contact Us | Communiquez avec nous
Continuing Education Department
B111
819-778-2270
ext.
1779
conted@cegep-heritage.qc.ca
