Community Integration Through Co-operative Education (CICE) Program Application Form Applicant Name * Required First Last Date of Birth MM slash DD slash YYYY OCAS # Address * Required Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell Phone * RequiredApplicant Email Address * Required Loyalist College Program Area(s) of Interest:For example: Carpentry and Renovation Techniques/Technician, Child and Youth Care, Fitness and Health Promotion, etc. Please refer to our website to view all the programs offered at Loyalist College.Choice #1 * Required Choice #2 * Required Choice #3 * Required Name of Secondary School Attended: * Required Level of Achievement in Secondary School: * Required OSSD OSSC Certificate of Accomplishment Other Please describe: * Required Post-Secondary School attended (if applicable):Highest level completed at post-secondary level (if applicable): One or more courses Certificate Diploma Other Method of transportation:Student can navigate public transit independently. * Required Yes No We are working on it. CICE Students must provide their own transportation to and from the College and field placements. Technology AgreementStudents will need a laptop for their studies, note: Chromebooks are not suitable as a personal computer due to incompatibility with Loyalist’s Learning Management Systems.Consent Applicant acknowledges this agreement.CICE RESUMÉ FORMPlease fill in all three previous experiences if possible.Applicant Name * Required First Last OCAS #: Loyalist ID #: Address * Required Street Address City State / Province / Region ZIP / Postal Code Experience #1Position Company Supervisor Name * Required First Last How many hours per week: * Required Start Date * Required MM slash DD slash YYYY End Date MM slash DD slash YYYY Was the position paid? Yes No Was the applicant supported in this position? Yes No What level of support was provided? Part-time Check-in only Other Explain: Duties Performed/Skills Acquired: * RequiredExperience #2Position Company Supervisor Name * Required First Last How many hours per week: * Required Start Date * Required MM slash DD slash YYYY End Date * Required MM slash DD slash YYYY Was the position paid? * Required Yes No Was the applicant supported in this position? * Required Yes No What level of support was provided? * Required Part-time Check-in only Other Explain: Duties Performed/Skills Acquired: * RequiredExperience #3Position Company Supervisor Name * Required First Last How many hours per week: * Required Start Date * Required MM slash DD slash YYYY End Date * Required MM slash DD slash YYYY Was the position paid? * Required Yes No What level of support was provided? * Required Part-time Check-in only Other Explain: Duties Performed/Skills Acquired: * RequiredList the Interests/Hobbies/Recreational Activities/Clubs that you participate in at present: * RequiredREQUIRED ATTACHMENTSPlease attach the following documents in this application submission. All files must be in PDF or JPG form and saved as First Name, Last Name and Type of Document (e.g. John Smith Personal Goals letter). Maximum upload size is 5MB and five (5) documents.PERSONAL GOALS LETTERIn a one-page typed or handwritten letter, explain your goals, how you (the applicant) think the CICE program will help you meet your goals, and why you need a modified program. This letter must be prepared by the applicant without assistance.Personal Goals Letter * RequiredAccepted file types: pdf, jpeg, Max. file size: 1 GB.If you are able to upload your Personal Goals letter now, please proceed. *All files must be in PDF or JPG form and saved as First Name, Last Name and Type of Document (e.g. John Smith Résumé). Maximum upload size is 5MB and five (5) documents.ResuméAccepted file types: pdf, jpeg, Max. file size: 1 GB.If you are able to upload your resume now, please proceed. *All files must be in PDF or JPG form and saved as First Name, Last Name and Type of Document (e.g. John Smith Résumé). Maximum upload size is 5MB and five (5) documents.Individual Education Plan (IEP) * RequiredAccepted file types: pdf, jpeg, Max. file size: 1 GB.If you are able to upload your IEP document now, please proceed. *All files must be in PDF or JPG form and saved as First Name, Last Name and Type of Document (e.g. John Smith IEP). Maximum upload size is 5MB.High School Transcript (marks)Accepted file types: pdf, jpeg, Max. file size: 1 GB.If you are able to upload your high school transcript now, please proceed. *All files must be in PDF or JPG form and saved as First Name, Last Name and Type of Document (e.g. John Smith Transcript). Maximum upload size is 5MB.Psycho-Educational Assessment (if you have one)Accepted file types: pdf, jpg, Max. file size: 1 GB.If you have a Psycho-Educational Assessment and are able to upload it now, please proceed. *All files must be in PDF or JPG form and saved as First Name, Last Name and Type of Document (e.g. John Smith Transcript). Maximum upload size is 5MB and five (5) documents.In accordance with Section 39(2) of the Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c, F.31, this is to advise you that the personal information on this form is collected under the legal authority of the Ontario Colleges of Applied Arts and technology Act, 2002 and may be used and or disclosed for administrative, statistical and or research purposes of the College and or the ministries and agencies of the Government of Ontario and the Government of Canada, including but not limited to, tabulating and reporting data on Key Performance Indicators (graduate rate, graduate employment, graduate satisfaction and employer satisfaction). For more information, please contact Manager, Risk Contracts and Insurance, Sasha Alexander at salexander@loyalistcollege.com.
