First Nation Community Wellness Diploma Application Form

Discover the path between you and your dreams

REQUIREMENTS AND INFORMATION
First Nation Community Wellness Diploma Application Form

Answer all questions fully. The information provided is confidential and is used to assess applicant’s suitability for the program.

A complete application includes the following:

  1. Completed application form
  2. Letter of support from employer
  3. If under 21 years old - high school transcript (applicant must meet University of Manitoba admission requirements).
  4. If mature student (over 21 years old) - proof of age e.g. driver’s license, treaty card, birth certificate
  5. Post-secondary education history (official transcripts)
PERSONAL INFORMATION
Use your full, legal name.
  Last Name*:  
First (Given) Name*:
Middle Name(s):
Preferred First Name:
Date of Birth (yyyy-mm-dd)*:
Address:
City/Town:
Province:
Postal Code:
Day Phone:
Evening Phone:
Email address*:
  *Required information
ANCESTRY
If you are Aboriginal indicate:  
Indicate First Nation Band / Home Community:  
Important: Provide a copy of your Treaty Status or Métis card. The Access Programs reserves the right to request verification of Aboriginal ancestry.
EMPLOYMENT HISTORY / VOLUNTEER AND COMMUNITY INVOLVEMENT
List your work experience, beginning with your current or most recent job
Employer Job Title / Position Dates (DD/MM/YY) Reason for Leaving
A letter of support from my employer is being attached to this application?  
  • Upload a letter of support from your employer file
  • (Required file format: PDF only, not larger than 4 Megabytes.)
If no, what arrangements are being made to have it reach our office?

Sponsoring Agency/Band:  
Contact Person:   Phone:  


List all volunteer experience and community involvement that you have had in the past five years
Organizations (Name and Place) Year(s) Involved Your Function

Do you need to add additional employment history and/or volunteer/community involvement?  
Type the additional information in the box below:

EDUCATION
Name of school
Location
Highest grade obtained
Date completed
Have you received upgrading since you left school?  
If you answered yes to the above question. was it:
Adult Basic EducationGED
Please indicate level completed:
Date Completed:
Are you currently enrolled in an upgrading program?
What is the completion date?  
Have been enrolled in any post-secondary education or training programs?
(I.e. Transition Year Program, Health Career Quest Summer Camp, Urban Circle,
college, university, nursing school, New Careers, Core Area Training, other provincially funded programs, etc.)
 
POST-SECONDARY EDUCATION - LIST ALL PREVIOUS AND CURRENT INSTITUTIONS. ATTACH OFFICIAL TRANSCRIPT(S)
University Degree obtained Date Completed
OTHER TRAINING - LIST ALL PREVIOUS AND CURRENT INSTITUTIONS
Institutions Diploma/Certificate obtained Date completed

  • Upload your transcript(s) file
  • (Required file format: PDF only, not larger than 4 Megabytes.)
  • (All your transcripts should be in one PDF file)
PREVIOUS UNIVERSITY APPLICATION INFORMATION
Have you ever applied for admission to the University of Manitoba?  
Faculty:   Year:   Student Number:  
Did you register and attend classes?  
If you have attended any institution/university, enclose an original transcript of your marks (use the EDUCATION section of this form). This is important for your application to be processed. Please contact us if you are having difficulties with this request.
Are you applying as a mature student (21 years of age and over)?
  • Please attach proof of age (e.g. driver’s licence, treaty card, birth certificate).
  • (Required file format: PDF only, not larger than 4 Megabytes.)
Documents attached:  
REFERENCES
Two submitted reference forms from people (other than relatives) are required. The online reference form can be found at extended.cc.umanitoba.ca/reference-form.

List their names, addresses, phone numbers, and position or organization below.
One of your references should be either a teacher or employer.
Name Address Phone Position/Organization
DECLARATION

All applicants are advised to read all application materials carefully. Failure to disclose relevant facts (including ALL previous attendance at post-secondary institutions) and/or submission of false information or documentation may result in acceptance and registration being withdrawn. If this information is discovered in a subsequent session it may result in dismissal from the University. Registration at a post-secondary institution subsequent to the submission of this application must be declared in writing.

  • I hereby certify that I have read and understood the instructions and information on this application form and on the Application Guide and that all statements made in connection with this application are true and complete.
  • I understand that the application fee submitted with this form is non-refundable and not credited towards the tuition fees.
  • I authorize the University to verify any information, transcripts or reference letters provided as part of this application.
  • I accept that any information on falsified documents may be shared with the Association of registrars of the Universities and Colleges of Canada.
  • I hereby authorize my high school/university to release my academic record/s should the need arise to accelerate the processing of this application.
Your application will not be considered if you have not included the following:

  • Application/Access Programs
  • Transcripts (high school, post-secondary, other training programs)
  • Two completed reference forms
  • Proof of Aboriginal Ancestry, if applicable
  • Short essay
  • Financial information
  • Signed declaration
  • Application/University of Manitoba

(Note: a separate application must be submitted to U of M Admissions Office)

Notice Regarding Collection, Use, and Disclosure of Personal Information by the University
Your personal information is being collected under the authority of The University of Manitoba Act. The information you provide will be used by the University for the purpose of admission, registration, assessment of academic status, eligibility for the program, and communication with the student. Your personal information may be disclosed to other educational institutions, government departments and co-sponsoring organizations for reporting purposes. For those students who are members of the University of Manitoba Students’ Union, your information will be disclosed to UMSU. Your personal information will not be used or disclosed for other purposes, unless permitted by The Freedom of Information and Protection of Privacy Act (FIPPA). If you have any questions about the collection of your personal information, contact the Access & Privacy Office

(tel. 204-474-9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2.

Notice of Disclosure of Personal Information to Statistics Canada
The Federal Statistics Act provides the legal authority for Statistics Canada to obtain access to personal information held by educational institutions. The information may be used only for statistical purposes, and the confidentiality provisions of the Statistics Act prevent the information from being released in any way that would identify a student. At any time, students who do not wish to have their information used are able to ask Statistics Canada to remove their identifying information from the national database. Further information on the use of this information can be obtained from Statistics Canada’s website (statcan.gc.ca) or by writing to the Post-Secondary Section, Centre for Education Statistics, 17th Floor, R.H. Coats Building, Tunney’s Pasture, Ottawa, Ontario, Canada, K1A 0T6.

LETTER OF INTENT
The purpose of this section is 1) to assist us in learning more about you and 2) to provide us with an initial assessment of your writing skills. Organize in an essay format (intro, body, conclusion). Elaborate on the following list of topics:

  1. What is your educational goal? (Describe)
  2. How is this program relevant to your work and your career/career goals?
  3. What do you hope to learn while in the program?
  4. What kinds of program supports will assist you to successfully complete the Diploma (academic, social or personal supports)?

STATEMENT OF RELEASE
I hereby authorize Aboriginal Focus Programs of the Extended Education, The University of Manitoba, to forward any marks and attendance earned in the program indicated to the employer or sponsor below.

NAME OF PROGRAM: FIRST NATIONS COMMUNITY WELLNESS DIPLOMA
Name:   Date:  
EMPLOYER TO WHOM ABOVE INFORMATION SHOULD BE SENT:
Name of organization:  
Contact person:   Title:  
Address:   City/Town:  
Province:   Postal code:  
Day phone:   Evening phone:  
SPONSOR TO WHOM ABOVE INFORMATION SHOULD BE SENT:
Name of organization:  
Contact person:   Title:  
Address:   City/Town:  
Province:   Postal code:  
Day phone:   Evening phone:  

Notice Regarding Collection, Use, and Disclosure of Personal Information by the University
Your personal information is being collected under the authority of The University of Manitoba Act. The information you provide will be used by the University for the purpose of disclosing grades and/or attendance to an authorized employer or sponsor. Your personal information will not be used or disclosed for other purposes, unless permitted by The Freedom of Information and Protection of Privacy Act (FIPPA). If you have any questions about the collection of your personal information, contact the Access & Privacy Office (tel. 204-474-9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2.


To the best of my knowledge, I certify that the information contained in this application is true and complete. I realize that any false statement contained in this application may result in my disqualification for or from this program.   (Check this box to accept)