Application for Health and Social Service Programmes

2. Personal DetailsLegal surname:

Date of birth:

1. Programme Details

This form is to be completed in addition to the Application to Enrol form

New Zealand Diploma in Enrolled Nursing

Bachelor of Nursing

Bachelor of Social Work

Which programme are you applying for?

3. Education History

Was your schooling completed in English?

If you are currently studying NCEA, do we have your permission to access your NCEA records online?

If you are currently studying, what is the name of your school/learning institution?

Please list the subjects you are studying and their NCEA/NZQA level :

School/Learning Institution Country Year

Yes No

Yes No

Have you ever been enrolled in another nursing, social work or paramedic programme? If yes, please provide details of where and when.

Yes No

Day Month Year

Bachelor of Nursing M-aori

July 2019

Subject Level Subject

Level

Bachelor of Health Science (Paramedic)Mental Health and Addiction Support Strand

Community Health Work Strand

Wellbeing (Level 4)

Yes No

Peer Support Strand

(Level 3)

4. Curriculum VitaePlease attach a copy of your current CV/resume outlining:

• your employment history (including full-time, part-time and voluntary work)• your personal interests, community activities, membership of clubs, etc

Name

Cultural Mentor

Do you require regular or periodic treatment from medical/health practitioners? Yes No

Have you ever been under the care of a psychiatrist? Yes No

Yes No

If you answered yes to any of the above questions, please provide further details below.

5. Referee Reports

Please in Section 1 of both Referee Reports and give the forms to two people who are willing to be your referees. Ask them to complete the forms and return them either to yourself or to Information & Enrolment, Whitireia New Zealand, DX Box SX33459, Porirua 5022 or scan and email to enrolments@whitireia.ac.nz within ten days. Please note your application cannot be processed until both referee reports have ben received.

The referee cannot be a relative, or close friend, and school leavers must have one referee report from their school.

.

6. Academic and Cultural Mentors

NURSING MĀORI/PACIFIC APPLICANTS ONLY

Please provide the name of people who are able to you ongoing support during your study. The cultural mentor must. have advanced knowledge of your culture and be trusted and respected by you. The academic mentor should be someone who has undertaken tertiary studies and is currently practising as a registered nurse.

Academic Mentor

7. HealthWhile health issues are not usually a barrier to acceptance into our programmes, the following questions help us determine whether you have any health issues that may your ability to practise safely. As some health issues may make it to manage clinical practice and/or full-time study, the Selection Committee may wish to discuss these with you or require you to complete a medical examination.

Do you, or anyone in your family, have any physical or mental health problems which could your ability to meet the requirements of a demanding programme with a clinical/practicum component? If so, please state the problem and outline support/strategies needed.

Name

8. Personal Statement

Why do you want to study the programme you are applying for?

Tell us about yourself (including your life experiences, values, beliefs).

YesI understand that I will be safety checked and/or police vetted as part of the entry requirements for this

POLICE VETTING

If you are eligible under the Criminal Records (Clean Slate) Act 2004, your conviction history may only be released under certain circumstances. Further information on vetting can be found at: www.police.govt.nz/advice/businesses-and-organisations/vetting/information-about-vetting

On receipt of the police vetting results, any concerns would be discussed with you; if these concerns are of a serious nature, they could jeopardise your enrolment in the programme. The information supplied by the Police will be securely stored until such time it is no longer required for the purpose obtained.

9. Safety Check

Do you have any convictions? If yes, please provide details below. Yes

Are there any investigations or other matters that may be disclosed about you in the safety checking process? If yes, please provide details below. No

Please provide details of any reason, including past events, you might be perceived to pose a risk to children (or others)?

No

No

Yes

If accepted into the programme, you will be required to complete a NZ Police ‘Request and Consent’ form, whereby you consent tothe NZ Police releasing any information they hold to Whitireia, if relevant to the purpose of the vetting request. This includes:

Conviction history and infringement/demerit reports; active charges and warrants to arrest; charges that did not result in conviction; any interaction you have had with NZ Police considered relevant to the role being vetted; information regarding family violence; and information subject to name suppression, where the information is necessary to the purpose of the vet.

The Children’s Act (2014) requires all students, who may work with children during the course of their study, to be safety checked.The safety check will include an interview, an identity check, review of your work history, police vetting as a ‘non-core’ workerand an overall assessment of your safety to work with children. Students not working with children may be police vetted to meetthe entry requirements for their programme.

Pursuant to Principle 11(d) of the Privacy Act 1993, I agree to the disclosure and use of the information on this form by Whitireia to authorised bodies in response to requests under statutory authority.

of genuine documents. No information that has been provided is incorrect. No information which could have a material bearing on my enrolment has been withheld. I understand that under the Privacy Act 1993, I have the right of access to all personal information held by the polytechnic about me, and I also have the right to ask the polytechnic to correct any information which is inaccurate. I have an obligation to advise the polytechnic of any changes to the personal information I have provided when this occurs.

Signature Date

Day Month Year

Full Name of Applicant

To ensure we are able to process your application, have you:

Completed all required sections of this form? Signed the Declaration (Section 11)?

Attached a copy of your CV/resume?

has been signed by a solicitor, Justice of the Peace (JP) or kaumatua as being a true copy of the original. If you are applying to enrol in person, original documents will be photocopied and returned to you.

10. Declaration

11. Checklist

Referee reports are: Attached to this application

Being sent by your referees

OFFICE USE ONLY

Application for Enrolment form

Parent/Guardian Signature (if under 18)

Application for Health and Social Services

Academic/Cultural mentors details (BNP, BNM)

Curriculum Vitae

Email application acknowledgement