CICE program application form

Dark blue graphic circles on a white background.

Applicant Name*
First Last
Date of Birth
MM slash DD slash YYYY
OCAS #
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone*
Applicant Email Address*
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*
Choice #2*
Choice #3*
Name of Secondary School Attended:*
Level of Achievement in Secondary School:*
- OSSD
- OSSC
- Certificate of Accomplishment
- Other
Please describe:*
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.*
- Yes
- No
- We are working on it.
CICE Students must provide their own transportation to and from the College and field placements.
Technology Agreement
Students 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 FORM
Please fill in all three previous experiences if possible.
Applicant Name*
First Last
OCAS #:
Loyalist ID #:
Address*
Street Address City State / Province / Region ZIP / Postal Code
Experience #1
Position
Company
Supervisor Name*
First Last
How many hours per week:*
Start Date*
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:*
Experience #2
Position
Company
Supervisor Name*
First Last
How many hours per week:*
Start Date*
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:*
Experience #3
Position
Company
Supervisor Name*
First Last
How many hours per week:*
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Was the position paid?*
- Yes
- No
What level of support was provided?*
- Part-time
- Check-in only
- Other
Explain:
Duties Performed/Skills Acquired:*
List the Interests/Hobbies/Recreational Activities/Clubs that you participate in at present:*
REQUIRED ATTACHMENTS
Please 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 LETTER
In 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*
Accepted file types: pdf, jpeg, Max. file size: 25 MB.
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 2MB.
Resumé
Accepted file types: pdf, jpeg, Max. file size: 25 MB.
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 2MB.
Individual Education Plan (IEP)*
Accepted file types: pdf, jpeg, Max. file size: 25 MB.
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 2MB.
High School Transcript (marks)
Accepted file types: pdf, jpeg, Max. file size: 25 MB.
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 2MB.
Psycho-Educational Assessment (if you have one)
Accepted file types: pdf, jpg, Max. file size: 25 MB.
If you have a Psycho-Educational Assessment and are able to upload it now, please proceed. if you receive an error please email in confidence to Rschock@loyalistcollege.com *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 2MB.
CAPTCHA
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.

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CICE program application form

Loyalist College Program Area(s) of Interest:

Post-Secondary School attended (if applicable):

Method of transportation:

Technology Agreement

CICE RESUMÉ FORM

Experience #1

Experience #2

Experience #3

REQUIRED ATTACHMENTS

PERSONAL GOALS LETTER

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