Fred Smithers Centre

Please Complete all portions before submitting

Please complete the following application if you wish to become a Fred Smithers Centre client and receive services. Your application will be processed based on the date received, submitted medical documentation and an intake appointment. Becoming a Fred Smithers Centre client is a 3-step process. Documentation of a disability must be provided however a diagnosis does not need to be disclosed.

Last Name
First Name
Date of Birth
E-mail

Program


Student Number (if known):
A


Are you visiting from another institution?
 


If yes, which institution?


Student Status:


Disability Information
 








You will be contacted for an intake meeting by the Secretary when Documentation is received and this application has been submitted.