U of R Student I.D. Number
Application for
Academic Recovery Program
SEMESTER FOR WHICH YOU WOULD LIKE TO BEGIN

FALL (Sept-Dec)


WINTER (Jan.-April)
SPRING/SUMMER (May-Aug.)
PERSONAL INFORMATION AND CURRENT MAILING ADDRESS
Last/Family Name
First Name
Middle Name
Mr.
Preferred Name (if different than First)
Previous Name (if applicable)
Ms.
Miss
Phone: Business
(
Address – Apt #, Street or Box #
Mrs.
Other _________
Ext.
306 )
Phone: Cell
(
City/Town
Prov./Country
Postal Code
Phone: Home
(
)
E-mail
Emergency Contact Name and Phone Number
)
Citizenship
Canadian
Citizen
Permanent
Resident
(Landed Immigrant)
Student Visa
(Student Authorization)
Country of Citizenship: _____________________
Other: _____________________________
Country of Citizenship: _____________________
LAST OR CURRENT ATTENDANCE AT THE UNIVERSITY OF REGINA
Campus (U of R or Federated College)
Faculty
Degree/Certificate/Program
Last Semester Attended
Students are eligible for the Academic Recovery Program only if the University of Regina was the last Post-Secondary Institution
Please attach a personal statement describing in 500 words or less the problems that contributed to your poor performance
and how you think the Academic Recovery Program can help you resolve these problems.
BY ENROLLING IN COURSES AT THE UNIVERSITY OF REGINA, STUDENTS CONSENT TO THE COLLECTION, USE, AND DISCLOSURE OF PERSONAL
INFORMATION AS DESCRIBED IN THE SECTION OF THE UNDERGRADUATE CALENDAR ON FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY. FOR
FURTHER DETAILS, CONTACT THE REGISTRAR'S OFFICE AT (306) 585-4127. BY SIGNING THIS FORM, YOU ARE CERTIFYING THAT ALL QUESTIONS HAVE BEEN
ANSWERED IN FULL AND THAT THE INFORMATION PROVIDED IS CORRECT AND COMPLETE. YOU AGREE TO ABIDE BY UNIVERSITY OF REGINA RULES AND
REGULATIONS AND UNDERSTAND THAT OTHERWISE YOUR RE-ADMISSION TO OR REGISTRATION IN THIS UNIVERSITY MAY BE REVOKED.
_______________________________________________________
APPLICANT’S SIGNATURE
____________________________________
DATE
This is a two semester program costing $900/semester. Application forms and personal statements may be sent by mail, e-mail or fax,
or may be dropped off in person to:
Student Success Centre
Riddell Centre 230
University of Regina
3737 Wascana Parkway
Regina, SK S4S 4T1
Toll Free: 877-666-0822
Phone: 306-585-4076
[email protected]
When your application form is received, you will be contacted by an Intake Counsellor to discuss your application. Application
decisions will be made by the Intake Counsellor in consultation with your faculty.