T e T a r i M ā t a u r a n g a H a u o r a F a c u l t y o f N u r s i n g a n d H e a l t h S t u d i e s Diploma in Enrolled Nursing Application Checklist Name of Student... Nursing & Health Studies: Please find enclosed the following: Completed application form signed and dated Verified copy of passport/ birth certificate/ Marriage Certificate - (If applicable) Private Bag 94006 Manukau City Auckland New Zealand Telephone +64 9 968 8736 Facsimile +64 9 968 8709 www.manukau.ac.nz Verified copy of qualifications Verified copy of New Zealand Permanent Residency if not born in the country Verified copy of IELTS ( if indicated that English is your 2 nd language) Verified copy of First Aid Certificate Medical certificate NZ Police Consent to Disclosure A verified copy is a photocopy that an authorised person who has sighted the original document has confirmed and signed eg Justice of the Peace or alternatively you can bring the original documentation to the Faculty of Nursing and Health Studies.
A. PERSONAL DETAILS Diploma in Enrolled Nursing Application Form OFFICE USE ONLY ID: Sent: SURNAME MR MRS MISS MS... ETHNICITY... FIRST NAME(S)... MALE FEMALE (Circle one) If your present name is different from that appearing on any transcript or examination results, please attach copies of appropriate legal documents, eg marriage certificate, deed poll certificates DATE OF BIRTH......... AGE (years)... FULL POSTAL ADDRESS...... PHONE (HOME)... PHONE (WORK)... MOBILE... EMAIL... IS ENGLISH YOUR SECOND LANGUAGE? If YES, were you educated in English? YES / NO (Circle one) YES / NO (Please provide evidence) If NO, what is your IELTS Score?... (Please provide evidence) NEW ZEALAND CITIZEN or RESIDENT (or from Australia, Tokelau, the Cook Islands, Niue) YES / NO (Circle one) B. PREFERRED TYPE OF STUDY DO YOU WISH TO ENROL FULL TIME PART TIME This will only be available if advertised C. EDUCATIONAL HISTORY SECONDARY SCHOOL TERTIARY INSTITUTION *PRIVATE EDUCATION TRAINING FROM -TO YEARS SUBJECTS TAKEN, IN FINAL YEARS QUALIFICATIONS AND GRADES GAINED (SEND PHOTOCOPIED PROOF) DO YOU HOLD A CURRENT FIRST AID CERTIFICATE? YES / NO EXPIRY DATE:... D. EMPLOYMENT HISTORY (If promoted with the same employer, please complete a separate line for each position held) EMPLOYER START DATE PART TIME FULLTIME (Circle one) POSITION FINISH DATE EMPLOYER START DATE PART TIME FULLTIME (Circle one) POSITION FINISH DATE EMPLOYER START DATE PART TIME FULLTIME (Circle one) POSITION FINISH DATE
INTERESTS/CURRENT STUDIES OR ACTIVITIES RELEVANT TO APPLICATION You may wish to add extra pages REFEREES Applicants are required to provide contact details of two people willing to provide a confidential reference. They must reside in New Zealand and may not be related to you and must have known you for longer than two years. (If you are unable to meet these requirements please feel free to discuss this with us). Please give each of these people a copy of the confidential reference form and ask them to return it immediately to the address at the bottom of this page. REFEREE 1 NAME CONTACT ADDRESS REFEREE 2 NAME CONTACT ADDRESS PHONE NUMBER PHONE NUMBER PERSONAL STATEMENTS Please answer all of the following by ticking one box for each question 1. Do you consider yourself to be fit & healthy?... 2. Do you have any health problems that require any ongoing medical treatment?... 3. Do you suffer from any physical or mental condition/impairment which could affect your performance on the Enrolled Nursing programme?... *You must provide a medical declaration / health certificate indicating ability to practice safely (from a registered health practitioner) 4. Have you had any criminal convictions or any pending convictions? ( other than minor traffic infringements)... *You must submit a NZ Police consent to Disclosure of Information form which will be sent to the Police Licensing and Vetting Service if accepted into the programme Your responses to the above questions will be discussed with you at your interview as they may influence your ability to meet programme requirements. INFORMATION REQUIRED You need to send certified copies of the following documentation to support your application. Tick each completed item. A copy of education results (successful or not) Marriage Certificate (if applicable) Workplace first aid certificate Proof of New Zealand Citizen or Permanent Residency Medical Certificate (as above *) DO NOT SEND ANY ORIGINAL DOCUMENTS Any letters of recommendation you wish to include NZ Police Consent to Disclosure ( as above *) I hereby declare that the information and attached documentation provided by me on this application form are true and correct. I acknowledge that Manukau Institute of Technology can cancel my application if false or incomplete information has been provided. I understand that the purpose of gathering this information is to allow Manukau Institute of technology to carry out the functions required of it under the Education Act 1989, and its obligation under other enactments and in accordance with the Privacy Act 1993. I authorise Manukau Institute of Technology to disclose this information to the agencies outlined in the Student Guide. SIGNATURE DATE A copy of the Privacy Act 1993 can be viewed in the Library and information on the Privacy Act is available in the Student Guide MARK YOUR ENVELOPE CONFIDENTIAL AND SEND YOUR APPLICATION TO: Faculty of Nursing & Health Studies Manukau Institute of Technology Private Bag 94006, South Auckland Mail Centre, Manukau 2240 NOTE: If you do not receive an acknowledgement of your application, or if you have any queries, please phone 09 968 8736
CONFIDENTIAL REFERENCE Diploma in Enrolled Nursing Mark your envelope Confidential and send to: Faculty of Nursing and Health Studies Manukau Institute of Technology, Private Bag 94006, South Auckland Mail Centre, Manukau 2240 NAME OF APPLICANT: Length of time you have known the applicant: Relationship to applicant: PERSONAL QUALITIES (Please note that relatives are asked not to complete this form) Please place an X in the space on the grid which best indicates your assessment of the applicant in relation to each of the following qualities. Honest Dishonest Mature Reliable Well Groomed Tolerant Accepts Responsibility Please comment on your assessment for this applicant s personal qualities: Immature Unreliable Untidy Intolerant Avoids Responsibility INTERPERSONAL RELATIONSHIPS (Please comment on the following) Relationship with peers: Consideration of others: WORK/STUDY ABILITIES (Please comment on the following) 1. Conversation skills 2. Written work 3. Practical skills 4. Problem solving 5. Independent work/study habits 6. Management of time 7. Cooperation with others 8. Perseverance 9. Initiative GENERAL Has the applicant s health ever affected his/her work performance at work/school? Is attendance pattern acceptable? If NO, comment Does the applicant have any special abilities or disabilities? Do you consider the applicant able to undertake the Diploma in Enrolled Nursing Programme? Please make any additional comments you wish: I wish this information to remain confidential SIGNATURE: POSITION: PHONE NUMBER: DATE:
CONFIDENTIAL REFERENCE Diploma in Enrolled Nursing Mark your envelope Confidential and send to: Faculty of Nursing and Health Studies Manukau Institute of Technology, Private Bag 94006, South Auckland Mail Centre, Manukau 2240 NAME OF APPLICANT: Length of time you have known the applicant: Relationship to applicant: PERSONAL QUALITIES (Please note that relatives are asked not to complete this form) Please place an X in the space on the grid which best indicates your assessment of the applicant in relation to each of the following qualities. Honest Dishonest Mature Reliable Well Groomed Tolerant Accepts Responsibility Please comment on your assessment for this applicant s personal qualities: Immature Unreliable Untidy Intolerant Avoids Responsibility INTERPERSONAL RELATIONSHIPS (Please comment on the following) Relationship with peers: Consideration of others: WORK/STUDY ABILITIES (Please comment on the following) 1. Conversation skills 2. Written work 3. Practical skills 4. Problem solving 5. Independent work/study habits 6. Management of time 7. Cooperation with others 8. Perseverance 9. Initiative GENERAL Has the applicant s health ever affected his/her work performance at work/school? Is attendance pattern acceptable? If NO, comment Does the applicant have any special abilities or disabilities? Do you consider the applicant able to undertake the Diploma in Enrolled Nursing? Please make any additional comments you wish: I wish this information to remain confidential SIGNATURE: POSITION: PHONE NUMBER: DATE: