Applicants from Diploma, Degree, and Certificate Health Care Programs Supplementary Application Form

Transcription

1 Applicants from Diploma, Degree, and Certificate Health Care Programs Supplementary Application Form Return no later than June 1 This form must be submitted if you have previously attended a professional health related diploma, degree, or certificate program. All information required in this application must be given in full or the application will not be considered by the Admissions Committee. False information will invalidate this application and may result in immediate rejection of the application or dismissal if the applicant has been admitted. This personal information is being collected under the authority of the University College of the North Act and will be used to evaluate the individual s application for admission to the Faculty of Health s academic programs. It is protected by the Protection on Privacy provisions of the Freedom of Information and Protection of Privacy Act. INSTRUCTIONS: Complete this form by printing with a black pen and return to: Enrolment Services University College of the North PO Box 3000 The Pas, MB, R9A 1M7 SUPPLEMENTARY APPLICATION FORM

2 APPLICANTS FROM DIPLOMA, DEGREE OR CERTIFICATE PROFESSIONAL HEALTH RELATED PROGRAMS Application and Instructions PART A PERSONAL DATA Family Name: UCN Student Number: Citizenship: Current Mailing Address: Given Name: Date of Birth: Mailing Address after April 30 (if different from current): Telephone No. Residence ( ) Business ( ) Telephone No. after April 30 (if different from above) Residence ( ) Business ( ) PART B DIPLOMA, DEGREE OR CERTIFICATE PROFESSIONAL HEALTH RELATED PROGRAM INFORMATION FROM PREVIOUS OR CURRENT PROGRAM Program Name: Name of Institution: Student Number: Name of Dean, Director, or Head of Nursing Program Length of Program: Dates Attended: SUPPLEMENTARY APPLICATION FORM

3 Mailing Address of Institution: Telephone No. of Dean, Director, or Head ( ) PART C REASONS FOR APPLICATION TO JBN, DPN, OR HCA PROGRAM In the space below, indicate your reasons for leaving the previous or current program and why you are applying to University College of the North. Please include why you believe you will experience more success in this program (attach additional pages if necessary): Signature: SUPPLEMENTARY APPLICATION FORM

4 CONFIDENTIAL Confidential Report Regarding a Nursing Applicant The following former student of your professional health program (e.g., nursing, midwifery, medicine, etc.) has applied to the Joint Bachelor of Nursing program or the Diploma in Practical Nursing program at the University College of the North. One of the requirements of applicants who attended but did not complete a previous certificate, diploma or degree health program is information about the applicant from the Dean, Director, or Head of that health program. Instructions: Please attach your letter to this form. In your letter, please indicate the applicant s status in your nursing program, including matters pending, with regard to failures, probation suspension, determination of professional unsuitability, disciplinary action or other related matters. SECTION ONE: Name of Applicant: Date of Birth: Nursing Program Attended: Dates of Attendance: SECTION TWO: Name of Dean, Director, Head of Nursing Program: Title: Name and Address of Institution: Postal Code: Telephone Number: ( ) Please submit the completed reference by June 1, to: Nursing Department Box 3000 University College of the North The Pas, MB R9A 1M7 Fax (204) CONFIDENTIAL REPORT NURSING APPLICANT

5 CONSENT for RELEASE of PERSONAL INFORMATION I, (print name), A/an (student/former student) at the (name of the health care program and institution where program is/was offered) and an applicant to the (JBN Program, DPN program, or HCA program) at University College of the North Authorize the (Head, Director, or Dean) of the above program at said University/College/Institution To release the following information: Status in the previous or current nursing program indicated above (including matters pending) with regard to failures, probation, suspension, determination of professional unsuitability, disciplinary action, or other related matters. This personal information can be released to: Admissions Office, Enrolment Services, University College of the North; and the Nursing Admissions Committee, University College of the North For the purpose of: Consideration of my application to either a) the Joint Baccalaureate Nursing Program, b) the Diploma in Practical Nursing or c) the Health Care Aide Program at University College of the North. I hereby state that I have read and understood the contents of this Consent for Release of Personal Information. I HEREBY GIVE MY CONSENT FOR THE RELEASE AND USE OF THE SPECIFIED PERSONAL INFORMATION AND I DECLARE THAT THIS CONSENT HAS BEEN GIVEN VOLUNTARILY. Date: Signature: Expiry Date: Signature of Witness: The Admissions Office and the Nursing Department at University College of the North will not use the information for any other purpose than that stated above, and will not further release this personal information without the further written permission of the individual that the information is about. CONSENT FOR RELEASE OF PERSONAL INFORMATION

6 GUIDE to COMPLETING "CONSENT for RELEASE of PERSONAL INFORMATION" (1) Indicate the date of signing. (2) An expiry date is optional. You or the University may find it necessary to specify a date when the consent expires. (3) Sign only when you have read and understood the entire form. (4) Your witness can be any adult who is not related to you. The witness can be a staff member of the department that holds and will be releasing your information. DEFINITION of "PERSONAL INFORMATION" Personal information means recorded information about an identifiable individual, including: a) The individual's name, b) The individual's home address, or home telephone number, facsimile or number, c) Information about the individual's age, sex, sexual orientation, marital or family status, d) Information about the individual's ancestry, race, color, nationality, or national or ethnic origin, e) Information about the individual's religion or creed, or religious belief, association or activity, f) Personal health information about the individual: Personal health information means recorded information about an identifiable individual that relates to: i. the individual s health or health care history, including genetic information about the individual, ii. the provision of health care to the individual, or iii. payment for health care provided to the individual, and includes i. the PHIN and any other identifying number, symbol or particular assigned to ii. iii. an individual, and any identifying information about the individual that is collected in the course of, and is incidental to, the provision of health care or payment for health care. Health care means any care, service or procedure: i. provided to diagnose, treat or maintain an individual s physical or mental condition, ii. provided to prevent disease or injury or promote health, or iii. that affects the structure or a function of the body, and includes the sale or dispensing of a drug, device, equipment or other item pursuant to a prescription. g) The individual's blood type, finger prints, or hereditary characteristics, h) Information about the individual's political belief, association or activity, i) Information about the individual s education, employment or occupation, or educational, employment or occupational history, j) Information about the individual s source of income or financial circumstances, activities or history, k) Information about the individual s criminal history, including regulatory offences, l) The individual s own personal views or opinions, except if they are about another person, m) The views or opinions expressed about the individual by another person, and n) An identifying number, symbol or other particular assigned to the individual. Clauses (a) to (n) of the definition "personal information" list examples of personal information. This list is not exhaustive, as the word "including" is used; clauses (a) to (n) do not set out the only information which is personal information (Provincial Government, Freedom of Information and Protection of Privacy Act, Resource Manual, 2002). CONSENT FOR RELEASE OF PERSONAL INFORMATION