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Registrars Office Admissions Supplementary Application 2020 (The Michener Institute of Education at UHN)

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SupplementaryApplication2020_V2 20-Mar-20
Registrar’s Office
Admissions
Supplementary Application 2020
Student Name: ________________________ Program: ____________________
Thank you for your application to the Michener Institute of Education at UHN. As the next step in the Admission process,
all applicants must submit this Supplementary Application Form. Failure to submit this form will result in your
application being withdrawn for 2020.
INSTRUCTIONS
Please review and agree to all statements below and then email your completed form to: regoffice@michener.ca
1. Mandatory Mask Fit Testing
I understand that all students must be mask fit tested and I have reviewed, understand and if offered admission, agree
to the Mandatory Mask Fitting Requirement Policy which requires students to be clean shaven.
Yes
No
2. Health Services Requirements
I am aware of Michener's mandatory Health Services Requirements and if offered admission, agree to submit all
documents by the program specified deadline.
Yes
No
3. MRI Screening Form (FOR APPLICANTS TO THE MRI PROGRAM ONLY)
I am aware of Michener's MRI screening requirements and if offered admission, agree to submit all documents by
the May 31, 2021 deadline.
Yes
No
4. WHMIS Training
I am aware that, if admitted, I will be required to annually complete the Workplace Hazardous Materials Information
System (WHMIS) training program during the first week of classes.
Yes
No
5. Michener Community Rights and Responsibilities
I have read, understand, and agree to abiding by the Michener Community Rights and Responsibilities if admitted to
Michener.
Yes
No
SupplementaryApplication2020_V2 20-Mar-20
6. Clinical Placements
I understand, if admitted to Michener, that I may be required to relocate to fulfill my clinical placement anywhere in
Canada as required by my program. I have read, understand, and agree to Michener’s Clinical Placement Policy.
Yes
No
7. Vulnerable Sector Check
I agree to provide an annual Vulnerable Sector Check (VSC) for each year I am registered with The Michener Institute of
Education at UHN. For 2020, if offered admission, I agree to submit all documents by the program specified deadline.
Yes
No
8. Health Professional Licensure Status
Have you ever had a health professional license revoked, suspended, restricted, limited, or subjected to any other
adverse action?
Note: Answering yes will not dismiss your application from consideration but may affect ability to secure clinical
placements to complete the requirements of a program, or to register with a professional regulatory college.
Yes
No
9. Criminal Charges or Convictions
Have you ever been charged with (where charges are still outstanding or unresolved) or convicted (not including traffic
violations) of an offense under any Provincial law, Federal statute or international law (other offenses) and/or have you
ever been charged (where charges are still outstanding and unresolved)?
Note: Answering yes will not dismiss your application from consideration but may affect ability to secure clinical
placements to complete the requirements of a program or to register with a professional regulatory college.
Yes
No
10. Personal Information
I agree that I have reviewed Michener’s Privacy Policy. I hereby specifically consent to allow Michener to collect and
disclose information pertaining to my Academic Record, Attendance Record and other information reasonably necessary
for purposes of certification, registration, and evaluation at Michener and/or for professional bodies for purposes of
Michener’s application for accreditation or application for support from any government, agency, or sponsorship
program. Agencies include but are not limited to affiliated academic and clinical education sites.
Yes
No
11. Participation in Learning Activities
Students enrolled in Michener's programs acquire basic technical skills under the supervision of qualified program
faculty by practicing real and/or simulated learning activities which at times may involve classmates, volunteers, and/or
other individuals. These activities can also be evaluated to determine competence acquisition. I agree to adhere to the
requirement of these learning activities. I also consent to my active participation in these activities and understand that I
SupplementaryApplication2020_V2 20-Mar-20
may be required to act as a simulated patient for other students. If I am unable to participate fully and safely in these
learning activities, I understand I must refer myself to the Health Nurse with a request for accommodation.
Yes
No
12. Recording of Learning Activities
Michener uses audio and visual recordings and photography to support learning activities and for the purposes of
evaluation. I consent to the use of audio-video recording and photography and to having myself recorded and
photographed recognizing it is an integral component of Michener's courses.
Yes
No
13. Confidentiality
I hereby agree to maintain the confidentiality of all learning activities, examinations, assignments and assessments
pertaining to my program. If I receive permission to write an exam/assignment/assessment, or, participate in a learning
activity in advance of its scheduled date, I agree not to divulge or discuss any information relating to the
exam/assignment/assessment in whole or in part to anyone. Further I agree to keep in confidence discussions or
outcomes of discussions to which I may be privy as a student representative serving on internal Michener committees. I
understand that a breach of confidentiality in either of these circumstances could result in my immediate dismissal from
the program.
Yes
No
14. Michener Rights
I understand that the Michener Institute of Education at UHN reserves the right to make changes to program availability,
program length, campus locations, or curriculum, or to adjust fees, admission requirements, policies or procedures at
any time. Michener would make such changes to meet competencies in the job market and/or as prescribed by its
governing Ministry, or for budgetary reasons or for other reasons it deems necessary. Michener shall not accept any
liability for the consequences of these changes.
Yes
No
Notes:
1. This form is required for your application to Michener.
Student Signature: _________________________ Date: ____________________
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Completed 10 February 2021

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