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The Québec Board of Black Educators

Da Costa Hall Summer Institute 2025 program

July 7 to August 1, 2025

Registration

COURSE SELECTION

What high school grade level are you registering courses for?

Course Select

Course*

Math

English

French

Course Select (10)

Course Select (11)

Course*

English

French

History

Mathematics (CST Option)

Mathematics (Science Option)

Mathematics Bridge (CST to SN)

Science & Technology (ST Option)

Science & Technology (AST Option)

Course*

English

French

Mathematics (CST Option)

Mathematics SN (Science Option)

Math 4 Bridge (CST to SN)

Subtotal

$ 0.00 CAD

Total

CONTACT INFORMATION

Student Information

Which Organization referred you?*

Other

Permanent Code*

Name*

First Name Last Name

Are you a returning student?*

Yes, from the Fall session

Yes, from past sessions

No, I am new

Address*

#civic, street Apartment City Province Postal Code

Date of Birth*

MM slash DD slash YYYY

Gender*

Any health conditions or allergies we should be aware of? Please list below.

Documents upload*

(including Individual Education Plan (IEP), Report Card, Speech-Language Pathology Test, other relevant assessments)

Drop files here or

Accepted file types: doc, docx, pdf, jpg, gif, png, Max. file size: 64 MB.

Choose your school board*

School

Cellular No

Email address*

CONTACT INFORMATION CONTINUED

Parent Information:

Parent*

Father

Mother

Guardian

Name*

First Name Last Name

Address same as student?

Yes

Address*

#civic, street Apartment City Province Postal Code

Home Phone*

Cellular No.

Email address*

Add Another Parent/Guardian?

Yes

Parent*

Father

Mother

Guardian

Name*

First Name Last Name

Same address as above?

Yes

Address

#civic, street / #civique, rue Apartment City Province Postal Code

(if different from the above one)

Home Phone*

Cellular No.

Email address*

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MEDIA RELEASE CONSENT FORM

This field is hidden when viewing the form

Complete The Media Release Form

Yes

I have already completed a form

I hereby give the Quebec Board of Black Educators (QBBE) the right and permission to record my image or likeness while I participate in the Project/Event identified below. Furthermore, I hereby irrevocably give QBBE the right and permission to use my image or likeness so recorded.

QBBE’s right of use shall include the right to publish, adapt, exhibit, reproduce, edit, distribute and display my image or likeness in connection with any product or service for any purpose (including marketing, promotion advertising and trade) in all markets, media or technology now known or hereafter developed.

For certainty, and without limiting the above, QBBE’s right of use shall also allow it to publish my image or likeness on the internet, incorporate my image or likeness into promotional videos and share my image or likeness with media organizations for any purpose.

I shall not have any entitlement to compensation for QBBE’s recording and use and shall not make any claim against QBBE, its affiliates, agents, event partners, governors, officers and/or employees for damages that may arise from its recording or use including, without limitation, any claim that is based on an alleged misrepresentation, negligence, defamation, breach of privacy, right of publicity infringement or an infringement of any applicable privacy legislation.

By signing my name, I acknowledge that I have read, understand and agree with the contents contained within this Consent and Release.

If under 18 years of age, a signature of a parent or guardian is required. I acknowledge that I have read and understood this Consent and Release. I agree to its terms in connection with the photographic or electronic records of the likeness of my child:

Select the platforms you wish to give permission for use:

I grant QBBE permission to use my image or likeness on QBBE’s Website
I grant QBBE permission to use my image or likeness on the QBBE Newsletter & Official Reports
I grant QBBE permission to use my image or likeness on the QBBE Facebook page
I grant QBBE permission to use my image or likeness on the QBBE Instagram page

Project/Event: Fall 2021 Academic Support

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Childs Name

First Last

This field is hidden when viewing the form

Parent or Guardian's Name

First Last

Payment Information

Processing Fee

Price: $ 0.00 CAD

Subtotal

$ 0.00 CAD

Total

Admin Code

Credit Card

Cardholder Name

Card Details

Phone

This field is for validation purposes and should be left unchanged.