I certify that the information contained herein and in the supporting documents is true, correct and complete. I understand that any incomplete disclosure, misrepresentation or falsified information on the application and supporting documents may result in the cancellation of/disqualification from a Scholarship, Award, or Named Bursary.

The information on this form is collected under the authority of the Michener Institute of Education at UHN and will be protected and used in compliance with the Ontario Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. F.31. I authorize the release of my personal information to The Michener Institute of Education at UHN for the purposes of determining my eligibility for a Scholarship, Award, or Named Bursary.

I consent to the use of my Student ID photo at the Student Awards Ceremony for presentation and visual publications, should I not provide my own photo. I also understand that my name will be published. Note: Incomplete applications will not be considered.