Registration Form
Choose your preferred way to stay connected
Student Name*

First Name

Last Name
Enter your First and Last Name
Gender *
Student Email
Student Phone Number
Date of Birth*

T-Shirt Size
We need your shirt size to order an Imhotep's T-Shirt for you
School Name*
Grade *
If your grade is not listed, please specify
Allergies or other medical conditions
List any medical conditions that we should know about
Career/Occupational Goals*
Tell us what you want to be in future
I would like to register for the following Programs*




Parent/Guardian First Name*
Parent/Guardian Last Name*
Relationship to Student*
Parent/Guardian Email*
Phone Number*
SMS Number
Enter a cell phone number where we can text you
Preferred method of contact*



How would you like us to contact you?
How did you hear about us?*
If other, please Specify how you heard of us
Address*

Address 1


Address 2

Country

City

State

Zip Code
Consent to still photos or videos*

I agree that still photos or videos (digital or otherwise) may be taken and reproduced in promotional materials, including brochures and bulletins.
I am African Nova Scotian, African Canadian or a person of African heritage (for statistics)*


Consent Form
A complete consent form is required to start ILA's programs. Upload a completed consent form that was previously provided to you OR click the link below to download the Consent Form.