Student Placement Application

    Contact Information

    First Name *

    Last Name



    City, Province, Postal Code

    Home Phone

    Cell Phone

    Work Phone

    E-Mail Address (school) *

    E-Mail Address (personal)

    Student Information

    School *


    School Year

    School Instructor

    Instructors Phone

    Instructors Email

    Placement Start Date

    Placement Days

    Placement Finish Date

    Placement Area of Interest

    Career ConnectionCommunity on CampusDay SupportsEarly Childhood Education Resource Services (ECERS)Peel Crisis Capacity Network (PCCN)Residential SupportsSummer Teen ActivityProgramUnsure


    Birthdate (Month and Day Only)


    Preferred Gender Pronoun

    Are you a current employee?

    Are you a former employee?

    Languages spoken?

    Why are you interested in a placement with Community Living Mississauga?

    Person to Notify in Case of Emergency


    Relationship to you

    Primary Phone

    Agreement and Signature

    By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a placement student, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

    Name (printed)



    If under 17 - Name & Signature of Parent/Guardian

    Name (printed)



    Our Policy

    It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.
    Thank you for completing this application form and for your interest in a Student Placement at Community Living Mississauga.