Collegiate Student Number
Student Name
Date of Application
Office Use
Application for Admission for Summer Session
1W02-515 Portage Avenue, Winnipeg, MB R3B 2E9
www.uwinnipeg.ca/collegiate
T: 204.786.9221
collegiate@uwinnipeg.ca
F: 204.775.1942
Initials
FOR NEW APPLICANTS include an official transcript of all high school credits completed.
PLEASE COMPLETE ALL SECTIONS OF THE APPLICATION FORM
Section A: Personal Information
Date of Birth
Gender :
||
Month
Day
Male
Female
Year
Student’s Full Legal Name
Family Name
First Name
Middle Name(s)
Permanent (Home) Address _________________________________________________________________________________
__________________________________________________________________________________________________________
Postal Code
Sessional (Winnipeg) Address if different ______________________________________________________________________
Postal Code
Home Phone Number________________________________ Cell Phone Number_____________________________________
Student Email_______________________________________ Citizenship and Immigration Status
Canadian Citizen
Permanent Resident*
International Student
*If a permanent resident, please provide a copy of permanent resident card/landed immigrant papers.
MB Health Number (6 digit)__________________________ MB Health PHIN Number (9 digit)___________________________
Do you have any chronic health concerns? __________ If yes, what are they? ____________________________________________
Emergency Contact (full name and phone)_____________________________________________________________________
Visiting Student Authorization
This applicant has permission to take for credit the course(s) indicated below at The University of Winnipeg Collegiate. The student has discussed his/
her course selection with me and I have deemed the course(s) to be appropriate to the student’s high school program. I understand that The Collegiate
reserves the right to require verification that course prerequisites have been met.
Name of Current School
Principal Name (Please Print)
Approved Collegiate course(s) (as listed on the attached form)
Principal Signature
Date
Section B: Tuition Fees (This section must be completed in full.)
My fees will be paid by myself, parent/guardian or sponsoring agency listed below. (Sponsored Students: please note that
a letter of sponsorship is required for final acceptance into your course/s.) I agree to accept financial responsibility for this
account.
Full Name (Please Print)
Signature
Date
Relationship to Student____________________________________________________________________________________
Address__________________________________________________________________________________________________
Postal Code
Phone
Fax
Sponsoring Agency Email Address___________________________________________________________________________
Should a student withdraw from their Collegiate course(s), any refund will be made payable to the person listed above.
Section C: Collegiate Policies
I have read and understood the following Collegiate Policies (must be signed by the parent/guardian if the student is under 18).
Full descriptions of these policies are available on The Collegiate website (http://collegiate.uwinnipeg.ca/admissions-can.php)
Photo & Video Release Policy
Instructional Activities Policy
Computer User Code of Ethics
Textbooks/Library Policy
Signature_____________________________________
Section D: Information Release
If you are under 18 years of age, The Collegiate is obliged by law to provide academic and personal information to your parents/guardians.
If you are over 18 years of age, or will turn 18 during the school year, please indicate below your wishes with respect to the release of such
information.
The Collegiate may release information regarding my attendance and grades to my parents/guardians should they request it.
Yes
No
Student Signature________________________________________ Date______________________________
Section E: Summer Courses
Please read the course descriptions in the 2015-16 Collegiate Calendar for specific information about prerequisites, etc.
Course selection counseling is available by email at collegiate@uwinnipeg.ca, phone, or an in-person appointment. Choose
the courses for which you wish to apply by placing a check mark to the left of the course title. The Collegiate reserves the
right to cancel courses for which there is insufficient demand.
Courses run Thursday, July 2 to Friday, August 7
Mondays to Thursdays (8:30 am - 11:30 am)
_____Applied Math 40S
_____Biology 40S
_____English Lit Focus 40S
Mondays to Thursdays (12:30 pm - 3:30 pm)
_____Chemistry 40S
_____Physics 40S
_____Pre-Calculus Math 40S
Tuition Fees:_______________ Credits x $720.00=________________CAD