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STUDENT REGISTRATION FORM 2020

Student's Full Name: REGINA COELI SANTANA JUAREZ
Student's Date of Birth: (MM/DD/YYYY) 09/19/2004 Student's Ad Astra Code: ( para ser llenado por la consutlora )

Name of School in Mexico: prepaenlinea.mx Returning Student: (YES/NO) NO

Current Grade in Mexico: SEGUNDO SEMESTRE Student's cel phone: 3334613854

Grade you will validate in Canada: UNIVERSIDAD Gender: (MALE/FEMALE) FEMALE

Student’s Email Address: regiinasantanaa@hotmail.com Home Phone: NA

Student's Full Address: CIRCUITO PUERTO VICTORIA 226 FRACCIONAMIENTO BANUS

(STREET NAME ) (NUMBER) (NEIGHBOURHOOD)

VERACRUZ VERACRUZ 95266 MEXICO

(STATE) (CITY) (ZIPCODE) (COUNTRY)

FAMILY INFORMATION
Father’s Full Name: FROYLAN SANTANA MANZANERA Mother’s Full Name: MARIA EUGENIA JUAREZ SANCHEZ

Father’s E-mail: mr.froy_santanaa@hotmail.com Mother’s E-mail: N/A

Phone/Cellphone: 3319650752 Phone/Cellphone: 2291476335

Name of Brother/Sister: SOFIA SANTANA JUAREZ Date of Birth: (MM/DD/YYYY) 03/28/1999

Name of Brother/Sister: N/A Date of Birth: (MM/DD/YYYY) N/A

EMERGENCY CONTACT (Not included Above)

Full Name: FROYLAN SANTANA MANZANERA Relationship: PAPÁ
E-mail: mr.froy_santanaa@hotmail.com Phone/Cellphone: 3319650752

PROGRAM INFORMATION
Type of Program: UNIVERSITY Period:
(PUBLIC, PRIVATE, BOARDING, CAMP, UNIVERSITY or LANGUAGE) ( #Y / #S / #W )

Program: (Code) Location: (City, Province)

Program Start Date: (MM/DD/YYYY) Program End Date: (MM/DD/YYYY)

AD ASTRA INFORMATION
Consultant's Full Single Name: Teresita Reyes Missett E - mail: tere@adastra.ca
Supervisor's Full Single Name: Teresita Reyes Missett E - mail: tere@adastra.ca

SPECIAL INTEREST OR ALLERGIES OF STUDENT THAT MAY AFFECT PLACEMENT: