Apply for Fall 2010

Last name:   First name:

Nickname (what you prefer to be called if different from first name:

Current mailing address:

Number & Street:   City:

Province/State:   Country:

Postal/Zip code:

Permanent mailing address:

Number & Street:   City:

Province/State:   Country:

Postal/Zip code:

Phone:    Fax:

Email address (able to receive attachments):

Alternate email address:

Emergency contact - Name:   Phone:

Sex (for housing assignments): female male

Date of birth: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990  

Social Insurance Number (for scholarships:)

Pertinent medical issues (kept confidential):

Member university you attend: UA UC UBC SFU UVIC UBCO

Non-member university you attend:

Student ID number:

BMSC programs previousy attended:

How did you learn about BMSC?

Reference Information:

Name of Professor who will recommend you:

University:

Phone: Email:

Course Prerequisites:

Academic standing as of May 1, 2010:

Field of study of degree with major:

Prerequisite courses: If you are currently taking a prerequisite course, enter 'TBD'

Boat Use: (PCOC = Pleasure Craft Operato'rs Card. SVOP = Small Boat Operator's Permit)

Please select A, B, C, or D below:

A) I do not wish to operate boats.

B) I have a PCOC number: or SVOP number:

C) I will obtain a PCOC and bring it with me.

D) If accepted, send me study material. I will pay $35 and write the PCOC exam when I arrive.

Do you plan to use SCUBA? NO YES

If YES, indicate you can bring required equipment. Note: BMSC provides SCUBA tanks ONLY.

Accommodation:

Students typically share rooms. If known, name your preferred roommate:

Do you plan to rent bedding? NO YES

Dietary preferences:

Meals always include a meat option and a vegetarian option. To help us determine how much food to order and prepare, please indicate your preferences below. If you indicate that you eat chicken, you will be expected to take the meat option when chicken is served. You may alter your preferences after you arrive by talking to kitchen staff.

Do you eat:

- a vegetarian diet? YES NO If YES, do you eat milk and eggs? YES NO

- beef? YES NO

- pork? YES NO

- chicken? YES NO

- fish? YES NO

List dietary sensitivities or allergies:  

List dietary preferences:

By submitting this form, I certify that the above information is complete and accurate. I acknowledge that failure to disclose complete and accurate information may result in denial of admission or dismissal from BMSC. I acknowledge that physical injury and death are risks inherent in the use of these facilities, and I assume all associated risks and I agree not to claim against BMSC for those risks. I agree to hold BMSC harmless from any and all injuries, damages and liabilities that may occur in the course of my visit, except for negligent acts or omissions of BMSC or its employees, students or agents acting in the scope of their duties.