Indigenous Student Centre - Academic Transition Opportunities

Note: This application is to be completed after the Ontario Universities Application Centre application.

Section 1 - Personal Information

Salutation:

First Name:

Last Name:

Western student #:

Email:

Faculty:

Program:

Birth Date:

Birth Month:

Birth Year:

Ancestry:
First Nations (Status) First Nations (Non-Status) Métis Inuit
Note: If applicable, please submit supporting documentation (e.g. Status Care) to Indigenous Services.

First Nations Community:

Will you be living on Western University Campus?
Yes No

Residence Name (if applicable):

Local Address:

Apt. #:

City:

Province:

Postal Code:

Primary Phone:

Additional Phone:

Home (Permanent) Address:

City:

Province:

Postal Code:

Do you have any dependents?
Yes No Prefer not to say

Dependent Name:

Age:

Relationship:

Dependent Name:

Age:

Relationship:

Dependent Name:

Age:

Relationship:

Dependent Name:

Age:

Relationship:

Will you require information for the following?

Child Care

Housing

Section 2 - Medical Information

This section is used to determine any health-related support you may required during the time you are a student at Western University.

Do you have any health concerns/conditions that you wish to disclose?

Do you have any mobility concerns?

Family Doctor Information:

Do you have a family Doctor?
Yes No

Name of Family Doctor:

Telephone:

Address:

City/Town:

Province/Territory:

Do you require a referral to a family doctor in London, Ontario?
Yes No

Section 3 - Financial Information

1. Have you applied for Financial Assistance/Sponsorship from your band?
Yes No Not Applicable

2. Are your books, tuition, supplies, and additional fees covered by a sponsoring agency?
Yes No Unsure

3. Have you applied for Financial Assitance from the Ontario Student Assistance Program?
Yes No

4. Have you applied for or will you be receiving Financial Assistance from another source?
Yes No Unsure

If yes, please specify

Section 4 - Additional Information

Please take the time to answer a few short questions to help us to get to know you better and to better assess your needs.

1. What are your Post-Secondary education goals? (Short and long term)

2. What are your strengths and weaknesses? (E.g. strength = well organized, weakness = writing, etc)

3. Is there any other information, questions, or concerns that you feel staff should know about to better meet your needs?

4. Many of our events/activities involve sharing of food. Do you have any dietary concerns that we should know about?

Section 5 - Privacy Statement

Personal information provided in this application will not be disclosed to any person(s) outside of the Student Development Centre, Indigenous Student Centre, or your Faculty at Western University, without your written consent. The information that you provide in this application is confidential, with the following exceptions:

We are required by law to report to the appropriate authorities any suspicions that a child (i.e. a person who is under the age of 16) has been or is being abused.
If you are in serious and imminent danger of hurting yourself or another person, we may need to reveal enough information to an appropriate third party to help you.
If you are involved in a legal proceeding, the court may subpoena our records. This is a rare occurrence, but you should be aware of the possibility.

There may be other unique situations where there are exceptions to confidentiality. However, these confidentiality exceptions will be fully outlined and disclosed to you by your counsellor when relevant.

Information about your faculty, year of study, citizenship, area of concern, and any referral source will be kept in your file. This data will also be used as part of an aggregate database in order to provide information about the client population served by the Student Development Centre. There will be no identifying information in the aggregate reports that are generated.

I hereby certify, to the best of my knowledge, that the information in this application package is true and correct. I acknowledge that any false statement contained in this application may result in my disqualification from this program.

To verify that you are a human, please enter the text below:

Contact Information:

For questions or concerns please contact Paul Porter @ 519-661-4095 or email pporter@uwo.ca

Indigenous Student Centre
Indigenous Student Transition Program Application 2022-2023

Section 1 - Personal Information

Section 2 - Medical Information

Family Doctor Information:

Section 3 - Financial Information

Section 4 - Additional Information

Section 5 - Privacy Statement

Contact Information:

Return to Indigenous Student Centre Website

Indigenous Student Centre Indigenous Student Transition Program Application 2022-2023

Section 1 - Personal Information

Section 2 - Medical Information

Family Doctor Information:

Section 3 - Financial Information

Section 4 - Additional Information

Section 5 - Privacy Statement

Contact Information:

Return to Indigenous Student Centre Website

Indigenous Student Centre
Indigenous Student Transition Program Application 2022-2023