Dual Credit Student Application

(Seneca Student ID Number)

Last Name (Legal) First Name (Legal) First Name (Preferred) Middle Name

Street Address (include Apartment/Unit number)

City/Town Province Postal Code

Home Telephone Alternate Contact Number Student's Personal Email Address (mandatory)

Date of Birth
Dual Credit Course Information
Year Month Day

Male College Course Code:

Canadian Status (Citizenship) Female Semester:
Other Gender
Identity Program: DUC
Language Spoken at Home / Mother Tongue

YRDSB TDSB DPCDSB

Name of Secondary School YCDSB TCDSB SCDSB

PDSB PVNCCDSB
Secondary School Contact Name and Email Address

Yes No High School Status

Have you been identified through an Identification,
Placement and Review Committee (IPRC) process?
Student OEN:
Do you have an Individual Education Plan (IEP)?
Grade Currently Attending:
Have you at any time dropped out of high school?
Credits Earned To Date:
Are you involved in a SHSM program?
Conditions of Registration
‐ Tuition fees will be paid in full by funds from the School College Work Initiative.
‐ Registrants must comply with Seneca's Student Rights & Responsibilities as outlined at
http://ww w.seneca colle ge.ca/ studentc onduct/rights ‐and ‐respons ibilities. html

FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT

The personal information collected on this form is in accordance with sections 21, 39 and 49 of the Freedom of Information and Protection of Privacy Act, and under
the legal authority of the Ministry of Colleges and Universities Act, R.S.O. 1990, Regulation 770, and the Ontario Colleges of Applied Arts and Technology Act, 2002,
Regulation 34/03. The information is used for the administrative and statistical purposes of Seneca College and/or the ministries and agencies of the Government of
Canada and the Government of Ontario. If you have any questions about the collection of your personal information, please contact Seneca College's Freedom of
Information & Privacy Protection Office at 416‐491‐5050, extension 77846, or email [email protected].

I have read the above statements and I hereby authorize the release and exchange of all records related to my registration, attendance, and
academic progress to the aforementioned as well as my Parent/Guardian and Secondary School Representatives͘

Student’s Signature Date

Parent/Guardian's Signature Date

(If under 18 years of age)

Secondary School Representative’s Signature Date

** Email [email protected].**
Consent To Use Personal Information
SENECA COLLEGE OF APPLIED ARTS AND TECHNOLOGY

Waiver, Indemnity and Release

I (print your name) ,

hereby consent to and authorize the use by Seneca College, its officers and employees, of my
image, voice and/or likeness and information about my student/employment status (i.e. program
name/year of graduation/former and current employers) and my work (i.e. images, artwork,
videos, photographs, reports, poems, written material, music, audio recordings and other
related materials/projects/works). Seneca College shall have the right to photograph, publish,
adapt, exhibit, perform, reproduce, edit, distribute, display or otherwise use my image, voice
and/or likeness and my work in connection with any product or service in all markets, media
or technology now known or hereafter developed in the College’s products or services, as long
as there is no intent to use the image, voice and/or likeness, and information about my student/
employment status, in a disparaging manner.

As well, I consent to have this information shared by Seneca College with third parties for these
same express purposes. Seneca College is not responsible for the misuse or alteration of any
such audio/video or photographs by third parties. I hereby release Seneca College and any of its
officers and employees from any and all actions, claims, loss or causes of action arising from the
use or misuse of such images.

I am 18 years of age or older and I am competent to contract my own name. I have read this
document before signing below, and I fully understand the contents, meaning and impact of this
consent, waiver, indemnity and release. This consent, waiver, indemnity and release is binding
on me, my heirs, executors, administrators and assigns.

SIGNATURE DATE

SIGNATURE OF PARENT/GUARDIAN (IF UNDER AGE 18) DATE

In accordance with sections 21, 39 and 49 of the Freedom of Information and Protection of Privacy
Act, the personal information including images and recordings in connection with this form is collected
under the authority of the Ministry of Colleges and Universities Act, R.S.O. 1990, and Regulation 770,
and the Ontario Colleges of Applied Arts and Technology Act 2002, Regulation 34/03. If you have any
questions about the collection of personal information, please contact Seneca College’s Privacy Office
at 416.491.5050 extension 77846, or email [email protected]. The mailing address for
the Privacy Office is 8 The Seneca Way, 8th Floor, Markham, Ontario, L3R 5Y1.
 Statement of Understanding
Dufferin-Peel CDSB & Seneca College Dual Credit Program
The Dual Credit Program offered at Seneca College requires me to spend a considerable amount of time working and learning
outside of my home school as a college/secondary school student. I will represent my school in a responsible manner and in
accordance with my school's Code of Conduct Policy.

I understand that I must follow all the rules of the Dual Credit Program:

I will:
 attend regularly and be punctual both at my home school, at Seneca College and (if applicable) at bus pick-up locations;
 if absent from class, report my absence to my instructor/teacher, at both the college and secondary school, before the start of the
day;
 complete all required assignments, tasks and tests;
 abide by the rules of Seneca College including appropriate behaviour and respect for persons and property; Seneca College
expectations will be outlined within the first week of the program;
 be required (if applicable) to wear safety shoes and will be required to wear other prescribed clothing for this program (e.g.
personal protective equipment) as directed by the instructor;
 carry my student ID with me and be prepared to present it to the bus driver and/or teachers/college instructors as requested;
 abide by the rules of the transportation organization and act responsibly on the bus/taxi/public transportation or my travel
privileges may be withdrawn;
 abide by Health and Safety regulations at Seneca College;
 work co-operatively and communicate in a positive manner with all instructors/teachers and peers.

I understand that:
 Seneca College instructors, coordinators, administrators and staff from Seneca College, Dufferin-Peel CDSB, and my secondary
school may as require, mutually share student information as related to the Dual Credit program (including student attendance and
academic performance, code of conduct issues and student Dual Credit application information). Information shared may be
disclosed to parents or guardians (if student is under the age of 18) upon their request;
 if I have an Individual Education Plan, I am responsible for accessing the college’s Student Accessible Services in order to
understand and receive the support services provided by the college;
 if I do not use the busing or transportation provided, I will be responsible for arriving punctually at Seneca College on the
arranged class dates;
 supervision will not be provided on the bus/public transit. The bus company and/or public transit can refuse service for
inappropriate behaviour;
 if I elect to travel as a passenger in a peer's personal or family vehicle, the district school board/college provide no insurance
coverage;
 travel insurance is not provided while traveling to/from the college. Students are encouraged to purchase Student Accident
Insurance available online at a nominal cost at www.insuremykids.com
 I must declare to my home school and college any medical condition which may seriously affect my participation in the program.
It is strongly recommended by the district school board/college that students obtain additional personal medical/accident
insurance as deemed necessary;
 Dufferin-Peel CDSB will not be held responsible for any liability or medical expenses arising out of participating in this program.
I understand that failure to comply with the above conditions/rules may result in my removal from the program and loss of academic credits.

______________________________________________
Student Printed Name

______________________________________________ _______________________________________
Student Signature Date

______________________________________________
Parent/Guardian Printed Name (if student is under 18 years of age)

______________________________________________ ________________________________________
Parent/Guardian Signature (if student is under 18 years of age) Date

One copy of this signed statement is to be retained with the secondary school, one copy is to be retained by the college, one copy to be retained by
the central board office and one copy is to be distributed to the student or, if the student is under 18 years of age, to the parent/guardian.
 MEDIA CONSENT FORM

SCHOOL: ______________________________________ SCHOOL YEAR: 2020-2021

To: Parent(s)/Guardian(s)/Student:

Schools cooperate with the media and other organizations, within reason, to promote the school board,
schools, programs and student accomplishments. However, we recognize that there are instances where a
parent/guardian may not wish their child photographed or recorded.

I hereby give the Dufferin-Peel Catholic District School Board and/or College and its employees
and agents:

(1) Permission to film/photograph/videotape or make an audio or digital recording of myself for purposes
related to my College Dual Credit course;

(2) The perpetual and non-exclusive right and license to use my image, my name and/or a quote from me
about or a description of my involvement in a work education program in any of the media communications
(i.e. print, audio, television, social media, online) promoting dual credit and experiential learning programs
produced by or on behalf of the Dufferin-Peel Catholic District School Board and/or College without payment
to me;

(3) Consent under the Freedom of Information and Protection of Privacy Act to use and disclose my image,
my name and/or a quote from me about or a description of my participation in any of the media
communications (i.e. print, audio, television, social media, online) promoting experiential learning
programs of the Dufferin-Peel Catholic District School Board and/or College.

Please be advised that all or portions of the work referred to above will become part of the media
organization's database and may be adapted for other educational or non-educational applications,
productions, broadcast, re-broadcast, published, exhibited, reproduced, and/or distributed in various media
formats to a number of markets.

To: The Dufferin-Peel Catholic District School Board

I HAVE READ AND UNDERSTAND THE INFORMATION PROVIDED ON THIS FORM. I VOLUNTARILY GIVE THE
DUFFERIN-PEEL CATHOLIC DISTRICT SCHOOL BOARD CONSENT TO INCLUDE MY CHILD OR ME IN THE MEDIA
COVERAGE AND ITS SUBSEQUENT USE DISCLOSURE AS DESCRIBED ABOVE.

I further understand that this consent is valid for the current school year and may be withdrawn by me at any
time, upon written notice. This Consent form meets the requirements of the Municipal Freedom of Information
and Protection of Privacy Act and the Education Act for the disclosure of personal information.

I CONSENT TO THE ABOVE: I DO NOT CONSENT TO THE ABOVE:

_________________________________ ___________________________________ _______________________

Name of Student (Please Print) If over 16 years of age, Signature of Student Date

_________________________________ ___________________________________ _______________________

Name of Parent/Guardian (Please Print) Signature of Parent/Guardian Date

Media Consent Form

 REMINDER:
ATTACH
CREDIT
COUNSELLING
SUMMARY
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