Rev.
Apr 25
, 2018
Funding Agency Sponsorship Agreement
STUDENT INFORMATION Student Number _______________________
Last Name _______________________________ First Name ____________________________ Middle Name or Initial _____________
Mailing Address _________________________________________________________________________________________________________
City _________________________________________________ Province ______________________ Postal Code ____________________
Telephone Home __________________________ Work _____________________________ Cell _______________________________
Release of Information
The funding agency named below has my permission to access my student records, registration and any personal information necessary for,
or pertaining to, my application and enrolment at North Island College.
Permission is in effect from __________________________________________ to _________________________________________________
MONTH DAY YEAR MONTH DAY YEAR
Student Signature ______________________________________________________________ Date (mmm-dd-yyyy)
__________________________________
COLLEGE INFORMATION (may be accessed on the website www.nic.bc.ca or contact an NIC advisor)
Intended Program and/or Courses
Term
and/or
Start/End Date
Estimated Fees
(includes tuition, lab, and
student union fees)
AGENCY INFORMATION
Agency Name __________________________________________________________________________________________________________
Mailing Address ________________________________________________________________________________________________________
City _________________________________________________________ Prov. ________________ Postal Code ____________________
Contact Name __________________________________________________ Title __________________________________________________
Telephone ___________________________ Fax __________________________ Email ____________________________________
We hereby undertake to sponsor the above named student in the above described program/course(s) for:
Fees as estimated above or other amount $ __________________
Books as estimated above or other amount $ __________________
Learner Resource Fee ($5 per credit or equivalent for post-sec level courses only)
Application Fee $ 25.00
Assessment Fee $ 15.00
* Health & Dental Insurance Fee $275.00
*See http://nisu.ca/ for more information about mandatory Health & Dental fees and students can opt out if eligible.
Additional instructions _______________________________________________________________________________________________
Name & Title (print) _____________________________________________________________________________________________________
Signature _____________________________________________________________________ Date __________________________________
FREEDOM OF INFORMATION/ PROTECTION OF PRIVACY
I understand that this information, along with subsequent information, is collected under the authority of the College and Institute Act. This information will be protected and used in
compliance with the BC Freedom of Information and Protection of Privacy Act.
CAMPBELL RIVER CAMPUS
1685 South Dogwood Street
Campbell River, BC V9W 8C1
T (250) 923-9700/1-800-715-0914
E: forms@nic.bc.ca
COMOX VALLEY CAMPUS
2300 Ryan Road
Courtenay, BC V9N 8N6
T (250) 334-5000/1-800-715-0914
E: forms@nic.bc.ca
PORT ALBERNI CAMPUS
3699 Roger Street
Port Alberni, BC V9Y 8E3
T (250) 724-8711 /1-800-715-0914
E: forms@nic.bc.ca
MT. WADDINGTON CAMPUS
140 - 8950 Granville Street, Box 901
Port Hardy, BC V0N 2P0
T (250) 949-7912/1-800-715-0914
E: forms@nic.bc.ca