Fillable Dual Credit Application - University Form (North Island College)

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Dual Credit Application - University Form (North Island College)

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Country of origin: CANADA
File type: PDF

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BROWSE NORTH ISLAND COLLEGE FORMS

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Revised Oct 18, 2019 RETURN THIS PAGE TO NIC 1
Dual Credit Application for University Transfer
(for High School Students)
www.nic.bc.ca T: 1-800-715-0914 E: Admissions-CW@nic.bc.ca
North Island College Student Number
PEN: Personal Education Number
Legal Last Name / First Name / Middle Name
Preferred First Name
Mailing Address
City
Province
Phone: Home
E-Mail Address
Birth Date: YY/ MM/ DD
Gender
M F
Emergency Contact Name: __________________________
Phone: BUS__________________ HOME:________________
Canadian Citizen:
Permanent Resident: Country of Origin ______________________
(Voluntary Disclosure)
Disability/medical condition? Yes
NIC will provide you with information about receiving support services.
(Voluntary Disclosure)
Do you identify yourself as an Indigenous person?
Yes No
If yes, are you: First Nations Metis Inuit
Program
Use FULL program name as listed in the North Island College Calendar.
Campus/Centre
Start Term: Choose which session by entering the year beside the term.
Fall (Sept-Dec)/Year Winter(Jan-Apr)/Year Spring(May-June)/Year Summer(July-Aug)/Year
Courses
DECLARATION PLEASE READ THE FOLLOWING BEFORE SIGNING:
I declare that the information I have submitted on the application is true and correct. Completion of this application permits North Island College (NIC) to
request and/or confirm any information necessary to support my application for admission. Falsifying any document or information submitted will result in the
immediate cancellation of admission or registration at the College. I understand that this application is a request for admission and does not guarantee
admission to any program or course. Admission is subject to meeting program and course prerequisites and to space availability. Decisions on my admission
will be made only after the application fee and all required documents have been submitted. I agree to abide by the established rules and regulations of North
Island College, including those of the program in which I shall be registered.
For individuals admitted to a co-admission program with partner institutions, I understand that all the details of my application, studies, and student conduct
record will be shared openly between NIC and the partner institution.
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
Signature: __________________________________________________________ Date:_____________________________________
For Office Use Only
Received By _______________________________ Date and Time Received _______________________________
Revised Oct 18, 2019 RETURN THIS PAGE TO NIC 2
Office of the Registrar
2300 Ryan Road, Courtenay BC V9N 8N6
T: 1-800-715-0914 E: Admissions-CW@nic.bc.ca
DISTRICT CAREER EDUCATION FACILITATOR FORM
(to be completed by the School District)
_________________________________________
District
____________________________________________
Applicant/Student Name
This applicant has indicated an interest in studying at North Island College. Keeping in mind they would be studying
in an adult learning environment where they would be communicating with adults in a cooperative learning
environment, please answer the following questions.
Does this student have any identified special needs or learning challenges? ☐ YES ☐ NO
Applicants who require accommodations and supports must notify NIC/DALS six months before the start of their
program to provide time for required accommodations to be put into place.
Please comment on this student’s academic readiness and maturity to study in an adult environment?
___________________________________________________________________________________________
___________________________________________________________________________________________
Self-motivation and commitment to learning are important attributes for a successful learner at the post-secondary
level. How do you view this student in this regard?
___________________________________________________________________________________________
___________________________________________________________________________________________
Do you recommend this student to take the identified course(s)/program at NIC?
☐ No. I do not make a recommendation.
☐ Yes. I have worked closely with this applicant, and I believe they have shown readiness for this opportunity. I
support their application to NIC.
Is NIC to invoice the School District directly for any fees for this applicant?
☐ No. District Career Programs Coordinator/High School Counsellor will inform the Applicant how to request
reimbursement if applicable.
☐ Yes. District Career Programs Coordinator/High School Counsellor to complete attached School District
Sponsorship Agreement (attached) for NIC permission to invoice the School District directly.
Or
☐ Yes. District Career Programs Coordinator/High School Counsellor will provide NIC with letter of sponsorship
under separate cover. Note: Sponsorship letter must be received by NIC prior to fee deadline for student to
retain seat in program/courses.
____________________________________________________________ _______________________
Signature of District Career Programs Coordinator/High School Counsellor Date
________________________________________________
Email Address
____________________________________
Telephone
Revised Oct 18, 2019 RETURN THIS PAGE TO NIC 3
SCHOOL DISTRICT SPONSORSHIP AGREEMENT
For Dual Credit High School Students
(to be completed by the School District)
Office of the Registrar
2300 Ryan Road
Courtenay BC V9N 8N6
T: 1-800-715-0914 E: Admissions-CW@nic.bc.ca
We hereby undertake to sponsor:
____________________________________ in the _____________________________________________________
Name of Student Name of program or course(s)
From: _______________ to ________________ for the following amounts.
MONTH/ YEAR MONTH/ YEAR
Note: NIC Policy 4-04 Fees and Refunds applies to all dual credit students and their sponsors.
Please check applicable boxes:
☐ Assessment Fee $15.00
☐ Lab Fee
☐ Books up to $_________
☐ Tuition up to $___________
☐ Learner Fee
☐ NISU (Student Society)
Additional Instructions
School District Name ______________________________________________
Mailing Address __________________________________________________
City ______________________________ Prov. ____________________ Postal Code ____________
Telephone (___) _______________ Fax (___) _______________ Email ____________________________
_________________________________________ ______________________________________
Contact Name (print) Title (print)
_________________________________________ _____________________
Signature Date
Revised Oct 18, 2019 RETURN THIS PAGE TO NIC 4
Office of the Registrar
2300 Ryan Road
Courtenay BC V9N 8N6
T: 1-800-715-0914 E: Admissions-CW@nic.bc.ca
FREEDOM OF INFORMATION RELEASE
(to be completed by the Applicant)
North Island College is governed by the Freedom of Information and Privacy Act (FIPPA) and as such is not able to
discuss student progress and attendance with a parent/guardian without the permission of the applicant/student.
Your signature below provides permission to your parent/guardian to access your student record information.
I give permission to share information about my student record, including grades, attendance and performance with
my parent/guardian.
___________________________________________ _________________________
Applicant / Student Name (print) Birthdate
_________________________________________________ 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 and to conduct student related business at North Island College on my behalf.
Permission is in effect:
From ________________________________________ To: ___________________________________________
MONTH / DAY / YEAR MONTH / DAY / YEAR
Student Authorization:
I hereby give authorization as identified above:
Student Signature: ______________________________________________ Date: _________________________
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Dual Credit Application - University Form (North Island College)

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Completed 5 February 2021

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