Loyalist Registration Form - Earn Dual Credits

Dual Credit Application

Please complete the below fields:

OEN #*

Student's Legal Name*

First Middle (s) Last

Preferred Name

Preferred first name if different than legal first name.

Previous Last Name Used

Previous last name that has been used if different than legal last name.

Student's Date of Birth*

Gender*

Male
Female
Prefer Not To Disclose

Address*

Street Address Address Line 2 City Province Postal Code

Main Phone Number*

Secondary Phone Number

Student's Email Address*

What is your status in Canada? Please check all that apply.**

Canadian Citizen, born in Canada
Canadian Citizen, born outside of Canada
First Nations, Inuit, Metis, etc.
Landed Immigrant/Permanent Resident
Visa Student
Refugee Status
Other

Confirmation of Photo Release*

I hereby authorize Loyalist College to photograph and/or videotape me, and to publish or broadcast such photograph(s) or video(s) of me through various media, including the Internet or multimedia products. I understand and agree that Loyalist College is not responsible for the misuse or alteration of any such photographs and/or videotapes by third parties. I hereby release Loyalist College and any of its officers, directors, agents, employees or servants from any and all actions, claims, loss or causes of action arising from the use or misuse of such images.

Yes, I consent.
No, I do not consent.

Confirmation of Student Consent and Release of Documents - Confirmation must be affirmative*

I understand the commitment that I am making to the Dual Credit/School College Work Initiative (SCWI) program and that I must consent to the following in order to submit an application and participate in the program:

Personal information on this form is collected in accordance with the Freedom of Information and Protection of Privacy Act (FIPPA) and will be used for the application, admission and registration process. Information will be shared with the Ministry of Training, Colleges and Universities and Ministry of Education and may be shared with individuals, organizations and institutions approved by Loyalist College for program monitoring, research, marketing or funding purposes. Personal information will be retained by Loyalist College and permanently linked with student information databases in order to develop and maintain appropriate policies, programs and funding mechanisms.

The information is used for the administrative, academic and statistical purposes of Loyalist College to administer the School College Work Initiative specifically as outlined below:

- Registration and access to the college Student Information System; - Access to the College Learning Management System; - Tracking and reporting your grades, student success data and demographic data to your Secondary School, your School Board, Loyalist College administration, the Ministry of Education and the Ministry of Advanced Education and Skills Development. - Sharing Individual Education Plan (IEP) information if required to access appropriate accommodation for learning.

I hereby consent and authorize the release and disclosure of the above stated information upon registering for the dual credit program.

Course Selection

To be completed by a Guidance, Student Success, Co-op or OYAP teacher who is coordinating Dual Credit participation for your high school.

Dual Credit Course*

Is The Student Planning On Taking A Second Dual Credit*

Yes
No

Academic Information

To be completed by a Guidance, Student Success, Co-op or OYAP teacher who is coordinating Dual Credit participation for your high school.

Grade*

10
11
12

School Board*

Secondary School*

Does the student have a current IEP (Individual Education Plan)?*

Yes
No

Does the student belong to the Target Group?*

"Target group" based on evidence of disengagement/underachievement as outlined on the "Evidence of Suitability" form

Yes
No

Is the student returning to secondary school for this program?*

i.e., has the student previously stopped attending or dropped out?

Yes
No

Is the student currently working towards a SHSM (Specialist High Skills Major)?*

Yes
No

Is the student an OYAP participant?*

Yes
No

Name

This field is for validation purposes and should be left unchanged.