James Bay Lowlands Secondary School Board

Department of Experiential Learning

 

 

 

 

 

 

 

 

Prospective Student Application Package

 

 Northern Lights Secondary School

Department of Experiential Learning

Student Application Form


Student Information

 

Last Name: _________________________________

 

First Name: _________________________________   Initial: ______

 

Date of Birth:    _______/_______/_______________

                               Day     Month            Year

Address: ______________________________________________________________________________

 

Telephone: (          ) ____________________________

 

Social Insurance Number: ___________ ___________ ___________

 

Allergies/Medical Conditions: _____________________________________________________________

 

Emergency Contact

 

Last Name: _____________________________ First Name: _____________________________

 

Relationship to Student: ____________________________________________________

 

Telephone: Work: (          ) ____________________ Home: (         ) _______________________

 

Family Doctor: _________________________  Telephone: (         ) _______________________

 

Health Card Number: ______________________________________________________

 

Academic Information

 

List the grade 11 & 12 course codes that you have successfully completed.

 

_____________________     _____________________    _____________________

_____________________     _____________________     _____________________

_____________________     _____________________     _____________________

 

List 3 career choices that interest you

1: ____________________________________________________________

2: ____________________________________________________________

3: ____________________________________________________________

 

Do you have an employer who would be interested in having you as a Coop/OYAP student? 

Yes ___________  No ____________ (if “yes”, fill in below)

 

Contact Name: ___________________________________________________________

 

Business Name: __________________________________________________________

 

Telephone: (        ) _______________________________

 

List details about any employment/volunteer experience that you have in the table below

 

Job Title

Employer Name

Duties

Start/End Dates

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have a driver’s license?  Yes __________  No ___________

Do you have access to a vehicle?  Yes __________  No ___________

 

 


-         During the course of the year, it will be necessary that student information be passed onto employers, teachers etc.

-         Information such as S.I.N. and Health Card numbers will be used for W.S.I.B. (insurance) coverage, and will be kept on record (secure location) for 1 year.

-         Your child’s picture and name may be used for publicity reasons while your child is a Coop/OYAP student (see Photograph Release Form).

-         Each student will require at least 2 references (non-family) before being accepted into the experiential learning program (See Reference Form).

 

Please sign and return this form along with:

-         A signed “Photograph Release” form

-         A signed “Statement of Understanding” form

-         At least 2 completed “Reference” forms

 


“I hereby acknowledge that the information contained in this application is true, and understand that false statements may result in removal from the Coop/OYAP program”

 

_______________________________________________   _____________________

                               Student Signature                                                       Date

 

_______________________________________________  ______________________

                        Parent/Guardian Signature                                                Date

 

_______________________________________________  ______________________

                              Teacher Signature                                                        Date

Statement of Understanding Form

 

I understand that I must conform to all rules of the program with respect to the following:

$                    Regular attendance and punctuality both in school (all courses) and on the job.

$                    Completion of all required assignments both in school (all courses) and on the job.

$                    The Cooperative Education Program requires me to spend a considerable amount of time working in the community, and as such, I will represent the school in a favourable manner.

$                    Abiding by the rules of the community organization where I am placed. 

$                    Employers may ask that your placement be terminated with their organization for failing to meet basic expectations required by other employees.  You may be required to find your own alternative placement should this situation arise.  Do as asked, and ask how it can be done better!

$                    Working the required hours of the job as determined by the Employer.

$                    Communication must be respectful and positive with all people associated with the program.

$                    Working cooperatively with my colleagues and teachers in school and on the job.

$                    Maintain strict confidentiality regarding workplace matters.

$                    Maintain professional working relationships with teachers and co-workers.

 

I understand that:

$                    I must call both my employer and the school if I have to be late or absent from my placement.

$                    The job that I will be performing as part of my coop placement is related to school credits.

$                    I will NOT be paid for my work term.

$                    The coop placement will take priority over part-time employment and that any adjustment to the work hours must be co-operatively arranged with my coop teacher and coop supervisor.

$                    I am responsible for arranging and paying for transportation to and from the worksite (if required, water taxi & helicopter paid by school).  I understand that it is the recommendation of the school that I use taxi service, bicycle or walk to the placement, rather than use a car.  I understand that if I choose to drive a car to work, I will be covered by my own insurance.

$                    I must declare to the coop teacher any medical condition that may affect my coop placement.  I understand I may have to undergo a medical examination or provide medical information to my training station for placement purposes.  I understand that I may be required to have immunization or other medical procedures done for certain placements, at my own expense.

$                    Some placements may require a security check, character check, credit check, or other screening before placement can be secured.  The school will not cover costs for these checks.

$                    Certain placements may require another set of specialized application forms and subsequent interviews prior to acceptance of a student.

$                    I may have to wear prescribed clothing for my placement (e.g. safety equipment, business attire, etc. - depending upon the placement and job description).  The school may not cover costs for this material.

$                    I must observe all health and safety regulations on the job.

$                    My coop teacher will have to provide pertinent information about me to a prospective supervisor for placement purposes.

$                    I can be removed from the Coop/OYAP Program if I am unable to meet program requirements either in school or on the job.  All credits will be lost if this is the case.

 

 


“I hereby acknowledge that I have read and understand the information contained within this form.  I also acknowledge that deliberate and/or repeated infractions related to the expectations listed on this form may lead to my removal from the Coop/OYAP program, with loss of all credits”

 

       _______________________________________________   _____________________

                                      Student Signature                                                       Date

 

       _______________________________________________  ______________________

                                Parent/Guardian Signature                                               Date

 Northern Lights Secondary School

Department of Experiential Learning

Student Photograph & Name Release Form

 

 

 

 

I, ________________________________________________________ give my permission to be photographed, and to have my name used by the department of experiential learning at Northern Lights Secondary School for promotional purposes. 

 

 

I understand that my photograph(s) and name will be used in promotional material that highlights the achievements of Cooperative education/OYAP students such as flyers, newsletters and posters. 

 

 

_______________________________________________   _____________________

                               Student Signature                                                       Date

 

 

_______________________________________________  ______________________

                        Parent/Guardian Signature                                                Date

 

 

_______________________________________________  ______________________

                              Teacher Signature                                                        Date

 

 

 

 

 

 

 

 

 

Northern Lights Secondary School

Department of Experiential Learning

Reference Form

 

Student Name:    _________________________________________________

 

Reference Name: _________________________________________________________

 

1)      How long have you known this student? _________________________________

2)      In what capacity? ___________________________________________________

3)      In your opinion, would this student represent NLSS favourably in the community?

Yes ______  No _______

 

 

Please rate the student by placing a

check (ü) in the appropriate column.

1 = POOR    10 = EXCELLENT!!

1

2

3

4

5

6

7

8

9

10

Is always PUNCTUAL.

 

 

 

 

 

 

 

 

 

 

Is RESPONSIBLE and RELIABLE.

 

 

 

 

 

 

 

 

 

 

Is DEDICATED and DETERMINED (Works to FULL POTENTIAL)

 

 

 

 

 

 

 

 

 

 

Is a HARD WORKER.

 

 

 

 

 

 

 

 

 

 

Has the ability to MEET DEADLINES.

 

 

 

 

 

 

 

 

 

 

Has good TEAMWORK skills & gets along with peers.

 

 

 

 

 

 

 

 

 

 

Is able to ACCEPT CRITICISM.

 

 

 

 

 

 

 

 

 

 

COMMUNICATES effectively (oral & written).

 

 

 

 

 

 

 

 

 

 

Is CONSCIENTIOUS.

 

 

 

 

 

 

 

 

 

 

Maintains good GROOMING and HYGIENE.

 

 

 

 

 

 

 

 

 

 

 

Additional Comments: ______________________________________________________________

 

Signature: _________________________________  Date:_______________________

 

Please return to          Matt Turner, c/o Northern Lights Secondary School

P.O. Box 304

Moosonee, Ontario.  POL 1YO

Northern Lights Secondary School

Department of Experiential Learning

Reference Form

 

Student Name:    _________________________________________________

 

Reference Name: _________________________________________________________

 

4)      How long have you known this student? _________________________________

5)      In what capacity? ___________________________________________________

6)      In your opinion, would this student represent NLSS favourably in the community?

Yes ______  No _______

 

 

Please rate the student by placing a

check (ü) in the appropriate column.

1 = POOR    10 = EXCELLENT!!

1

2

3

4

5

6

7

8

9

10

Is always PUNCTUAL.

 

 

 

 

 

 

 

 

 

 

Is RESPONSIBLE and RELIABLE.

 

 

 

 

 

 

 

 

 

 

Is DEDICATED and DETERMINED (Works to FULL POTENTIAL)

 

 

 

 

 

 

 

 

 

 

Is a HARD WORKER.

 

 

 

 

 

 

 

 

 

 

Has the ability to MEET DEADLINES.

 

 

 

 

 

 

 

 

 

 

Has good TEAMWORK skills & gets along with peers.

 

 

 

 

 

 

 

 

 

 

Is able to ACCEPT CRITICISM.

 

 

 

 

 

 

 

 

 

 

COMMUNICATES effectively (oral & written).

 

 

 

 

 

 

 

 

 

 

Is CONSCIENTIOUS.

 

 

 

 

 

 

 

 

 

 

Maintains good GROOMING and HYGIENE.

 

 

 

 

 

 

 

 

 

 

 

Additional Comments: ___________________________________________________________________________________

 

Signature: _________________________________  Date:_______________________

 

Please return to          Matt Turner, c/o Northern Lights Secondary School

P.O. Box 304

Moosonee, Ontario.  POL 1YO