Adult Community Education
(ACE) Enrolment Form
FOR OFFICE USE ONLY:
COURSES
Please write the full name of the course you are applying for:
Emergency Contact Person:
Contact
Relationship to you
Phone
Please supply us with current contact information so that we can
keep you informed of your application status.
Home Phone
Mobile
Email
Work Phone
Do you have a preferred contact method?
Post Email Text (mobile)
Any
Street Address
Suburb
Town/City
Postcode
Mailing Address while studying at UCOL
Yes No
If Yes, your Student ID
National Student Index (NSI) Number (if known)
Date of Birth:
Day Month Year
Title: Mr Ms Mrs Miss
Other, please specify
Have you previously enrolled at UCOL, Manawatu Polytechnic,
Wanganui Regional Community Polytechnic or Wairarapa
Community Polytechnic before?
Legal First Name(s)
Legal Surname
Preferred Name(s)
Legal Gender: Male Female
Preferred Gender (optional):
If you have previously enrolled at UCOL, Manawatu Polytechnic,
Wanganui Regional Community Polytechnic or Wairarapa Community
Polytechnic under a different name, what was that name?
1 PERSONAL INFORMATION
2
NSN Status
Which UCOL campus will you be studying at?
Palmerston North Auckland
Whanganui
Wairarapa
Other
Citizenship & Residency Status:
New Zealand Citizen
Australian Citizen/Permanent Resident
New Zealand Permanent Resident
Other, please specify
What ethnic group(s) do you belong to?
If you identified as New Zealand Maori, please specify Iwi
SECONDARY SCHOOL EDUCATION
Name of last secondary school attended:
3
Which years did you study from at your last secondary
school?
to
SECONDARY SCHOOL EDUCATION
(continued)
No formal secondary qualification
14 or more credits at any level
NCEA Level 1 or School Certificate
NCEA Level 2 or Sixth Form Certificate
University Entrance
NCEA Level 3 or Bursary or Scholarship
Overseas qualification (includes International
Baccalaureate and Cambridge Exams)
Other - specify
3
What is the highest level of achievement you hold from a
secondary school? (Please tick one box only)
Please mail completed form to:
UCOL Information Centre
Private Bag 11022
Palmerston North
Freepost 460
Or drop it into one of our Information Centres:
Cnr of Princess and King Streets, Palmerston North
143-159 Chapel Street, Masterton
16 Rutland Street, Wanganui
Contact us:
0800 GO UCOL
0800 46 8265
Website: www.ucol.ac.nz
Email: enquiry@ucol.ac.nz
September 2016
PRIOR ACTIVITY
Please tick only one box.
Secondary School student
Self-employed
Private Training Establishment student
Non-employed or beneficiary (excluding retired)
University student
House-person or retired
Overseas - specify:
Wage or salary worker
Polytechnic/Institute of Technology student
Wananga student
4
What was your main activity or occupation in New Zealand on
the 1st October prior to the date of your programme starting?
Blind
Specific learning disability
Mobility
Vision impaired
DISABILITY DETAILS
Do you live with the effects of an injury, long-term illness or
impairment?
Yes No
If yes, please indicate your condition/disability by ticking the
boxes that apply to you.
Deaf
Speech
Hearing impairment
Psychological/
Psychiatric disability
Medical - specify:
Other - specify:
Reasonable additional support is available for students with
medical conditions, disabilities and/or learning difficulties.
5
Signature Date
Day Month Year
6 ACKNOWLEDGEMENT & DECLARATION
I hereby apply for admission and enrolment at UCOL and I understand and
agree to the following:
a) As soon as UCOL receives my ACE Enrolment Form and verified proof of
my identity, I have a conditional contract to study at UCOL.
b) That my enrolment at UCOL is subject to UCOL sending me a
Confirmation Letter.
c) That if I receive a UCOL Confirmation Letter I will participate in course/s
I am enrolled in and use my best efforts to successfully complete those
course/s.
d) I undertake to comply with all UCOL’s statutes, policies and procedures.
(these are available through the UCOL website www.ucol.ac.nz).
e) UCOL collects and stores the above information about you relating to
your studies. In signing the ACE Enrolment Form, you authorise the
collection and holding of this information. Under the Privacy Act 1993
you may ask UCOL to provide you with copies of the information it holds
about you. If you disagree with any such information you may ask to
have it corrected.
f) UCOL can use any photographs/videos and/or recordings taken of me for
the purpose of marketing and media during and after my enrolment at
UCOL. I agree to sign other documents required by UCOL for this
purpose (if required).
g) That the information I have given UCOL is true, and complete in
all respects.
h) That I have read, I understand and I agree to the Acknowledgement
& Declaration section of this ACE Enrolment Form.
click to sign
signature
click to edit
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