OLTS APPLICATION FORM

G         Yes, I would like to register for this eight week on-line course for students with learning disabilities.

Name:   ______________________________________

Address:  _____________________________________

 _____________________________________________

Phone #:  _____________________________________

Email:  _______________________________________

College/University:  _____________________________

Program of Interest: ____________________________                                                                  

Print form and return $100 payment and form to:

Loyalist College

c/o SOAR Office, OLTS Course

P.O. Box 4200

Belleville, Ontario K8N 5B9

G         Cheque (payable to Loyalist College)

G         Credit Card Payment

            G         VISA    G         Mastercard  

            G         Other:

Card #:  __________________________________

Expiry Date:  ______________________________

Signature:  ________________________________