Shine

Shine

An Introduction to Everyday Self Care
Online learning programs are for students who qualify for APSEA services. Registration must be completed by their APSEA Education Support Teacher (EST).
Education Support Teacher Name:

First NameLast Name
Education Support Teacher Email Address:
example@example.com
Form Access
The email address entered ({est74}) is not on the approved user list for this form. Please verify the address entered or contact your supervisor if you require access.
Approved email address. You may complete and submit this form.
Session Selection
Please select the session you would like to attend on Wednesday, December 9:
Student Information
Student Name:

First NameLast Name
Grade:
If Other, please specify grade:
City/Town:
Province:
Parent/Guardian Information
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Email Address:
example@example.com
Deliver Materials
Where should the materials be delivered to:
Mailing Address Name:
Email Address:
example@example.com
Street Address:
City/Town:
Province:
Postal Code:
Education Support Teacher Name:

Other
Education Support Teacher Email Address:

Other
Education Support Teacher Province:
School Information
School District/Regional Centre for Education
School Name:
School Team Contact Name:
School Team Email Address:
example@example.com
School Team Member Role:
If Other, please specify:
In Class Support
Full Name:

First NameLast Name
Email Address:
example@example.com
Job Title:
If Other, Please Specify:
Please add any details about your student you feel would be helpful to know:
Feedback
How did you hear about this program?
If Other for how you found out about this program, please specify
A valid approved EST email address is required before this form can be submitted.
Should be Empty:

Shine

Session Selection

Student Information

Parent/Guardian Information

Deliver Materials

School Information

In Class Support

Feedback