Fillable Dual Credit Application Health And Human Services (North Island College)

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Dual Credit Application Health And Human Services (North Island College)

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Country of origin: CANADA
File type: PDF

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Revised Oct 22, 2019 RETURN THIS PAGE TO NIC 1
Dual Credit Application for Health and Human Services
(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
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 22, 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)
_____________________________________________ __________________________________________
Student Name District
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
________________________________ _____________________________________________________
Telephone Email Address
Revised Oct 22, 2019 RETURN THIS PAGE TO NIC 3
Office of the Registrar
2300 Ryan Road
Courtenay BC V9N 8N6
T: 1-800-715-0914 E: Admissions-CW@nic.bc.ca
SCHOOL DISTRICT SPONSORSHIP AGREEMENT for
Dual Credit High School Students
(to be completed by the School District)
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 22, 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 during the current academic year.
_____________________________________ ___________________________
Applicant/ Student Name (print) Birthdate
_________________________________________________ has my permission to access my student records,
Parent or Guardian Name (print)
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: _________________________
Revised Oct 22, 2019 RETURN THIS PAGE TO NIC 5
Office of the Registrar
2300 Ryan Road
Courtenay BC V9N 8N6
T: 1-800-715-0914 E: Admissions-CW@nic.bc.ca
NIC INSTRUCTOR SIGNATURE PAGE
______________________________________________ ___________________________________
Student Name District
NIC PROGRAM INSTRUCTOR
(Department Chair signature required if Instructor is not available; it is the student’s responsibility to take this form to
the instructor)
_______________________________________________ _______________________________________
Instructor Name Title
I have met with the applicant and discussed the following:
a. Program and course content
b. Level of skill necessary for successful program completion
c. Expectations of an adult learning environment
I believe they show readiness for this opportunity. I support their application to NIC. I understand that the applicant
must also meet the Program Admission Requirements and that my signature does not indicate an offer of Admission.
_____________________________________________ ______________________________________
Instructor Signature Date
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Dual Credit Application Health And Human Services (North Island College)

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Completed 5 February 2021

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