Collegiate Student Number
Student Name
Date of Application
Application for Admission for Canadian Students
FALL/WINTER SESSION 2015–16
1W02-515 Portage Avenue, Winnipeg, MB R3B 2E9
www.uwinnipeg.ca/collegiate
T: 204.786.9221
collegiate@uwinnipeg.ca
F: 204.775.1942
FOR NEW APPLICANTS include the following:
• An official transcript of all high school credits completed. Include an interim report card
if you are currently in school.
• A letter of reference from a teacher or administrator from your current school.
• A $100.00 non-refundable application fee. (Returning and visiting students do not pay.)
• Visiting Students who are currently enrolled at another high school must ensure the application is authorized by
your current school.
(Applicants for Concurrent Status should apply directly to The University of Winnipeg.)
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 _________________________________________________________________________________
__________________________________________________________________________________________________________
Sessional (Winnipeg) Address if different ______________________________________________________________________
Postal Code
Home Phone Number________________________________ Cell Phone Number_____________________________________
Student Email______________________________________________________________________________________________
Citizenship and Immigration Status
Canadian Citizen
Permanent Resident*
*If a permanent resident, please provide a copy of permanent resident card/landed immigrant papers.
If you are of Aboriginal ancestry, please specify (Provision of this information is voluntary.)
First Nations
Métis
Inuit
Uncertain of ancestry
Current School _________________________________________Current School Division ______________________________
Are you a high school graduate?
Yes
No Year graduated:_____________________________________________
Have you been suspended or expelled from another school during the previous 24 months?
Yes
No
If yes, please explain________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
MB Health # (6 digit)____________________________________ MB Health PHIN# (9 digit)______________________________
Do you have any chronic health concerns?
Yes
No
If yes, a Collegiate Dean will contact you to further assess if URIS forms are required to be completed.
Are there any other concerns that could have an impact on your ability to be successful at The Collegiate?
Yes
No
If yes, please explain:________________________________________________________________________________________ _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
This medical information is being collected so that appropriate health-care plans may be developed. This information will be shared only with the
appropriate individuals. This information is protected by The Personal Health Information Act. Questions should be directed to The Collegiate Dean.
Parent/Guardian Information
Father/Guardian Name
Family Name
First Name
Home Address (if different from student)_________________________________________________________________________
_________________________________________________________________________________________________________
Postal Code
Home Phone______________________ Alternate Phone________________ *Email___________________________________
Mother/Guardian Name
Family Name
First Name
Home Address (if different from student)_________________________________________________________________________
_________________________________________________________________________________________________________
Postal Code
Home Phone______________________ Alternate Phone________________ *Email___________________________________
Emergency Contact (full name and phone)_______________________________________________________________________
*Please note the email address provided may be shared internally among Collegiate Faculty, student groups and used for Collegiate communications.
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
Approved Collegiate course(s) (as listed on the back of this form)
Number of courses to be taken at current school during 2015/16 academic year
Principal Name (Please Print)
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: Special Interests and Extra-Curricular
Math/Science
Visual Arts
Literature
Computers
Sports
Art/Music/Drama/Dance
Other
Please list any school or extra-curricular activities in which you have been involved (e.g. clubs, athletics, music, arts, volunteer work, etc.)
_______________________________________________________________________________________________________________
Section D: Please let us know how you were referred to The Collegiate
Current Collegiate Student/Parent
Friend
Newspaper
Internet Search
Radio
Alumnus (parents, family)
Open House
Other______________
Section E: 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 F: 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______________________________
OFFICE USE ONLY
Application Fee
Provisional Acceptance Date/Initial
Final Acceptance Date/Initial
Section G: Fall/Winter Courses
Please read the course descriptions in The Collegiate Calendar for specific information about prerequisites, etc. Indicate
the courses for which you wish to apply by placing an 'X' to the left of the course title. The Collegiate reserves the right to
cancel courses for which there is insufficient demand.
Grade 10 Courses
���Art 20S
���Computer Science 20S
���Digital Media I 25S/35S
���Dramatic Arts 20S
���English 20F
���Français 20F
���French 20F
���Geographic Issues 20F
���Geographic Issues 20E
���Essential Mathematics 20S
���Intro to Applied and Pre-Calculus
Mathematics 20S
���Music Band 20S
���Music Choral 20S
���Physical Education 20F
���Reading, Thinking and Culture 20S
���Science 20F
���Spanish 20F
Grade 11 Courses
��� Art 30S
���Biology 30S
���Chemistry 30S
���Computer Science 30S
���Dramatic Arts 30S
���Digital Media II 35S
���Literary Focus 30S
���Transactional Focus 30S
(Creative Writing)
���Transactional Focus 30E
���Français 30S
���French 30S
���History of Canada 30F
���History of Canada 30E
���Applied Mathematics 30S
���Essential Mathematics 30S
���Pre-Calculus Mathematics 30S
���Pre-Calculus Mathematics 30S
(Mature)
���Music Band 30S
���Music Choral 30S
���Physical Education 30F
���Physics 30S
���Spanish 30S
Grade 12 Courses
EVENING COURSES: Sept–Dec
��� Art 40S
Monday & Wednesday: 6:30–9:30 p.m.
���Biology 40S
���Law 40S
���Chemistry 40S
���Literary Focus 40S
���Dramatic Arts 40S
Tuesday & Thursday: 6:30–9:30 p.m.
���Comprehensive Focus 40S (EAL)
���Economics 40S
���Literary Focus 40S
���Applied Mathematics 40S
���Transactional Focus 40S (EAL)
���Pre-Calculus Mathematics 40S
���Language and Literary Forms 40S
(Creative Writing)
���Language and Literary Forms 40S
EVENING COURSES: Jan–March
(Journalism)
Monday & Wednesday: 6:30–9:30 p.m.
���Family Studies 40S
���Economics 40S
���Français 40S
���Applied Mathematics 40S
���French 40S
���Essential Mathematics 40S
���History: Western Civilization 40S
���Pre-Calculus Mathematics 40S
���History: Global Issues 40S
���Law 40S
Tuesday & Thursday: 6:30–9:30 p.m.
���Applied Mathematics 40S
���Chemistry 40S
���Essential Mathematics 40S
���Language & Trans. Forms 40S
���Pre-Calculus Mathematics 40S
���Law 40S
���Pre-Calculus Mathematics 40S
(Mature)
���Music Band 40S
���Music Choral 40S
���Physical Education 40F
���Physics 40S
���Psychology 40S
���Spanish 40S
DUAL CREDIT COURSES
���Academic Writing 42U: RHET-1105/3
and Intro to University 42U: MULT-1000/3
���Intro to Computers 42U: ACS-1453/3
���Intro to English 42U: ENGL-1001/6
���Intro to Human Geography I and II 42U:
GEOG-1102/3, 1103/3
���Intro to Conflict Resolution Studies 42U
CRS-1200/6
���Intro to Calculus 42U: MATH-1106/6
���Intro to Chemistry 42U: CHEM-111/3.112/3
���Intro to Philosophy 42U: PHIL-1001/6
���Global Citizenship 42U: HRGS-1200/3
���Intro to Religious Studies 42U: REL-1002/6
TUITION FEES ______________________________ Credits x $830.00 =________________________________________ CAD
I hereby agree to honour all financial obligations in accordance with The Collegiate policies.
Student/Parent Signature
Date
OFFICE USE ONLY
Scheduled by (Initial)