CONTINUING EDUCATION
Application & Registration Form
Questions? Please call 1-800-715-0914 Last modified: 21-01-21
Personal Information
Have you ever attended North Island College? Yes No If yes, NIC student #: _________________________________
Legal last name: ______________________ First name: _____________________ Middle name: _______________________
Former last name, if applicable: _____________________________ Preferred first name: _______________________________
Mailing address: _________________________________________ City: ____________________________________________
Province: ___________________________ Country: _______________________ Postal code: ________________________
Home phone: ___________________ Other phone: ________________ Email address: _______________________________
Birthdate: ___________________________ Gender: M F
Emergency contact name: _________________________ Home phone: ______________ Other phone: __________________
Canadian Citizen Permanent Resident If permanent resident, country of origin:
International student If international student, country of origin: ___________________________________________________
Course Selection
Course code:____________________ Course name: _____________________________________________________________
For Sponsored Students Only
Sponsoring organization/company: __________________________________________________ PO #: ___________________
I hereby authorize the release of all academic records relating to my admission or education to the sponsoring agency.
Student signature: ___________________________________________________ Date: _______________________________
Voluntary Disclosure
Do you identify yourself as an Indigenous person? Yes No If so, are you: First Nations Métis Inuit
Do you have a disability/medical condition? Yes No NIC will provide you with information about receiving support services
DECLARATION
Please read the following before signing:
I declare that the information I have submitted on the application is true and correct. Falsifying any document or information submitted will result in the
immediate cancellation of admission or registration at the College. I understand that this information along with subsequent information is collected
under the authority of the College and Institute Act and section 26 of the Freedom of Information and Protection of Privacy Act (FOIPPA). Information
collected will be used for the purposes of: admissions, registration, grade notification, income tax receipts, research, awards, alumni contact, special
events and other activities consistent with the mandate of the institution. NIC collects, uses, retains and discloses information within the College to carry
out its mandate and operations in accordance to Policy 1-01 Freedom of Information and Protection of Privacy. Should you have any questions about the
collection of information please contact the FIPPA Analyst located at 2300 Ryan Road, Courtenay, BC, V9N 8N6, or email foipp@nic.bc.ca
Student signature: ___________________________________________________ Date: _______________________________
Payment Options
• ONLINE: Visit www.nic.bc.ca/continuing-education and click Register for Continuing Education Courses
• MAIL: Mail completed registration form to Student Services with payment by cheque with full fees. No post-dated cheques are
accepted. To help prevent credit card fraud DO NOT write your credit card information anywhere on this form.
• EMAIL: Save this completed form before sending (otherwise it will be blank). Email the completed form to NIC Comox Valley Continuing
Education: CETinfo-cv@nic.bc.ca. A staff member from the Continuing Education department will contact you to take payment when
the registration is processed.
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