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For Early Childhood Educators Taking Kindergarten Qualification Courses (Nipissing University)

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Statement of Experience Form
For Early Childhood Educators
Taking Kindergarten Qualification Courses
Office of the Registrar ● 100 College Dr., P.O. Box 5002 ● North Bay, Ontario P1B 8L7
●Tel: 705-474-3461 ext. 4760 ● Fax: 705-495-1772 ● www.nipissingu.ca/aq/ ● E-mail: registrar@nipissingu.ca
**This Statement of Experience form is to be used by Early Childhood Educators only. Certified teachers must
use the other Statement of Experience form posted at www.nipissingu.ca/aq.
A signed Statement of Experience form is required for all Part II and Part III courses.
The Statement of Experience has to be signed by a Supervisory Officer. (A Principal’s signature
does not satisfy this requirement)
For this purpose a Supervisory Officer is defined as follows:
a) For an Early Childhood Educator employed by a District School Board of Education, this person is a
Superintendent or Director of Education. A Principal’s signature does not satisfy this requirement.
Experience outside of Ontario must be certified by an appropriate supervisory official.
b) For an Early Childhood Educator employed by a private school, or First Nations Education
Authority, this person is the Ministry of Education official appointed to provide supervisory services
for the school. A Principal’s signature does not satisfy this requirement.
Please Note:
♦
All teaching experience as an Early Childhood Educator must be from the date of
initial ECE certification.
♦
Incomplete forms will not be processed.
The Statement of
Experience
form is due no later than the last day of the course but
preferably
prior to the course start date.
The Statement of Experience form can be mailed, faxed, scanned and emailed, or delivered to:
(You should keep a copy of the form before sending)
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**Faxed and emailed copies will be treated as original.
PRIVACY: Personal information in connection with this form is collected under the authority of the Nipissing University Act, 1992 for educational, administrative and statistical purposes. The information
will be used to process your enrolment and registration in academic programs; to record and track your academic progress; and for related record-keeping purposes. If you have any questions regarding
the collection, use and disclosure of this information by the University, please contact the Registrar’s Office, Nipissing University, Box 5002, North Bay ON P1B 8L7, (705) 474-3461, ext. 4521.
PRIVACY: Personal information in connection with this form is collected under the authority of the Nipissing University Act, 1992 for educational, administrative and statistical purposes. The information
will be used to process your enrolment and registration in academic programs; to record and track your academic progress; and for related record-keeping purposes. If you have any questions regarding
the collection, use and disclosure of this information by the University, please contact the Registrar’s Office, Nipissing University, Box 5002, North Bay ON P1B 8L7, (705) 474-3461, ext. 4521.
Office of the Registrar ● 100 College Dr., P.O. Box 5002 ● North Bay, Ontario P1B 8L7
●Tel: 705-474-3461 ext. 4760 ● Fax: 705-495-1772 ● www.nipissingu.ca/aq ● E-mail: registrar@nipissingu.ca
Statement of Experience Form
For Early Childhood Educators
Taking Kindergarten Qualification Courses
NAME OF APPLICANT:
___________________________________________
SESSION:
Spring (begins early March)
NIPISSING ID #:
Summer (begins early July)
COURSE REGISTERED IN:
__Kindergarten Qualification_________________
Spring/Summer (begins late May)
APPLICANT APPLIED FOR:
PART II;
PART III;
Fall (begins early October)
Winter (begins mid-January)
For this purpose a Supervisory Officer is defined as follows:
a) For an Early Childhood Educator employed by a District School Board of Education, this person is a Superintendent or Director of
Education. A Principal’s signature does not satisfy this requirement. Experience outside of Ontario must be certified by an appropriate
supervisory official.
b) For an Early Childhood Educator employed by a private school, or First Nations Education Authority, this person is the Ministry of
Education official appointed to provide supervisory services for the school. A Principal’s signature does not satisfy this requirement.
Please Note: ♦ Incomplete forms will not be processed.
♦ Faxed or scanned copies will be treated as originals.
Part II Course
Supervisory Officer’s Certification
I certify that the applicant named above has successfully
completed at least one (1) school year (194 days) of
successful teaching experience as an Early Childhood
Educator.
Name of Supervisory Officer (please print)
Signature of Supervisory Officer
Title of Supervisory Officer
Date
Name of School Board
Ext.
Telephone Number
Part III Course
Supervisory Officer’s Certification
I certify that the applicant named above has successfully
completed at least two (2) school years (388 days) of
successful teaching experience as an Early Childhood
Educator, including at least one school year (194 days) of
experience in a Kindergarten Classroom.
Name of Supervisory Officer (please print)
Signature of Supervisory Officer
Title of Supervisory Officer
Date
Name of School Board
Ext.
Telephone Number
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Completed 5 February 2021

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