APPLICATION DEADLINE: MARCH 31

If you have or will have completed 30 credit hours of university level work and are in good standing, please call
204-677-1454 or No Charge Dial 1-866-237-5509; you may need to complete a different application form. If this
does not apply to you AND you are at least 21 years of age, please complete this form.

ANSWER ALL QUESTIONS FULLY.

COMPLETE APPLICATION BY INCLUDING AND CHECKING OFF THE FOLLOWING REQUIRED

INFORMATION:

TRANSCRIPTS_____ TWO (2) REFERENCE FORMS _____ PROOF OF AGE _____

ALL INFORMATION ON THIS FORM IS CONFIDENTIAL AND IS TO BE USED ONLY IN

ASSESSING APPLICANTS ELIGIBILITY/SUITABILITY FOR THE PROGRAM.

APPLICATION TO BE COMPLETED IN APPLICANT’S HANDWRITING.

DO YOU WISH TO ATTEND OUR PROGRAM: FULL TIME [ ] PART TIME [ ]

A. PERSONAL HISTORY

Name:__________________________________________________________________
Last First Second

Present Address: _______________________________________________________________

_______________________________________________________________
____________________________________Postal Code________________
How long have you lived at this address? ________________________

Telephone: Home_________________ Work __________________ Cell ______________

E-mail: ____________________________________________________________
(**REQUIRED**)

Community of Origin (where you grew up):__________________________________

How long have you lived in Northern Manitoba?___________________________________

AGE: ___________________ DATE OF BIRTH: __________________________________

Month Day Year

SOCIAL INSURANCE NUMBER: _______________________________________________

ARE YOU A CANADIAN CITIZEN? Yes [ ] No [ ]

If not born in Canada, how long have you lived in Canada? ___________________________

ANCESTRY: (Please check one)

If Aboriginal: Status [ ] Non Status [ ] Metis [ ] Inuit [ ]

If Non-Aboriginal: Immigrant [ ] Refugee [ ] Other [ ]

Is English your first language? Yes [ ] No [ ]

What language(s) did you grow up hearing? ________________________________________

MARITAL STATUS:

Single Parent [ ] Single [ ] Married/Common-Law [ ]

DEPENDENT’S NAME (S) AGE RELATIONSHIP TO YOU

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

How many of the above are you supporting financially?______________________________

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B. PREVIOUS EDUCATION:

Formal Secondary: (Please circle the last full year completed.)

7 8 9 10 11(General) 11 (University Entrance)

12 (General) 12 (University Entrance)

Name & Location of

School(s):________________________________________________

The year your last grade was completed: _______________________

Secondary Upgrading:

Have you received upgrading since you left school? Yes [ ] No [ ]

If yes, was it: Circle level completed: Date Completed:

Adult Basic Ed. 8-10 11 12 ____________________

G.E.D. 10 11 12 ____________________

Other (specify) ___________________________________________________

Are you currently enrolled in an upgrading program? Yes [ ] No [ ]

If yes, what is the anticipated completion date? ___________________________________

Post Secondary: Have you been to any education programs after high school or any training
programs? (i.e. college, university, certificate, continuing education, upgrading, other provincial or
federal programs, etc) Yes [ ] No [ ] Please list below.

Institution Program Course Date of Did you complete

Organization Attendance the Program/
From To Course?
(M/Y) (M/Y)

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Have you completed/Are you currently taking:

Aboriginal CFS Diploma? Yes [ ] No [ ]

First Nations Community Wellness Diploma? Yes [ ] No [ ]

Applied Counselling at U of M? Yes [ ] No [ ] at RRCC or KCC? Yes [ ] No [ ]

If you have post-secondary education, enclose an original transcript of your

marks from all post-secondary institutions you attended. This is important for
your application to be processed. (It will be returned) Have you previously applied to
the Faculty of Social Work at Thompson?
Yes [ ] No [ ] U of M student number: _________________

C. EMPLOYMENT/COMMUNITY INVOLVEMENT:

1. Are you currently:

[ ] Employed Full-Time (30 hr/wk or more) [ ] Employed Casually

[ ] Employed Part-Time [ ] A Student [ ] A Volunteer

[ ] Unemployed

2. Employment History: (Begin with your present job)

Employer Position Dates (mth/yr to mth/yr) Reason for Leaving

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

3. Volunteer/Community Involvement: (List all volunteer experience and community involvement

that you have had in the past five years.)
Organizations (Name & Place) Years(s) Involved Your Function
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

-4-
D. FINANCIAL INFORMATION:

The financial information should be based on combined family income.

YOUR APPLICATION IS NOT COMPLETE UNLESS THIS SECTION IS COMPLETED

ACCURATELY. THIS INFORMATION WILL BE USED TO HELP IDENTIFY WHAT FUNDING
SOURCE MIGHT BE AVAILABLE TO YOU.

Your Monthly Income: Your Partner’s Monthly Income

Job Income ________________ ____________________

E.I. ________________ ____________________

Social Assistance ________________ ____________________

Family Allowance ________________ ____________________

Other (specify) ________________ ____________________

ANNUAL [ ] $0-5,000 [ ] $5,001-10,000 [ ] $10,001-15,000 INCOME

LEVEL: [ ] $15,001-20,000 [ ] $20,001-25,000 [ ] $25,001 plus

Have you ever applied for a Canada Student Loan? ______ If yes, year _______

IF SEEKING FUNDING SUPPORT THROUGH CANADA STUDENT LOANS

PLEASE NOTE: PERSONS IN DEFAULT ON PREVIOUS CANADA STUDENT LOANS OR WHO HAVE DECLARED
BANKRUPTCY SHOULD CONTACT THE MANITOBA STUDENT FINANCIAL ASSISTANCE PROGRAM (945-
6321 OR 1-800-204-1685) TO EXPLORE OPTIONS REGARDING FUNDING ELIGIBILITY.

How did you learn about the program?

Band Office [] Program Personnel [ ] Radio []

Student [] Human Resources [ ] Newspaper [ ]
School [] Social Assistance [] Career Days [ ]
Website []

Other
(specify)____________________________________________________

-5-
E. AUTOBIOGRAPHY: Using a pen with black ink, in your own handwriting and your
own words, please write a short autobiography. Include what you think we should know in
order to evaluate your suitability and readiness for the program. Since you shouldn’t
assume you will get an interview, it is important that you include information which tells us
why you want to be a social worker. Please stay within line boundaries. Insert extra pages
if necessary. (Do not write on the back.)

Your discussion must include the following information:

- where you were born and raised

- your participation in community activities
- your present family life and situation
- your personal strengths and weaknesses
- when and how you became interested in Social Work
- what you have done to pursue your interest in Social Work
- how your family and friends feel about you becoming a student - anything else which you
think we ought to know in order to assess your suitability for the program.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

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________________________________________________________________________
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________________________________________________________________________
________________________________________________________________________

-7-
F. DECLARATION:
Applicants are advised to read all application materials carefully. Failure to disclose relevant facts
(including ALL previous attendance at post-secondary institutions) and/or submissions of false
information or documentation may result in acceptance and registration being withdrawn. If this
information is discovered in a subsequent session it may result in dismissal from the University.
Registration at a post-secondary institution subsequent to the submission of this application must
be declared in writing.

! I hereby certify that I have read and understood the instructions and information on
this application form and that all statements made in connection with this
application are true and complete.

! I authorize the University to verify any information, transcripts or reference letters

provided as part of this application.

! I accept that any information on falsified documents may be shared with the
Association of Registrars of the Universities and Colleges of Canada.

! I authorize my high school/university to release my academic record(s) should the

need arise to accelerate the processing of this application.

Date: ___________________________________

Signature of Applicant: _______________________________________________

Notice Regarding Collection, Use, and Disclosure of Personal Information by the University

This personal information is being collected under the authority of The University of Manitoba Act. It will be used for
the purposes of admission, registration, assessment of academic status, eligibility for the program, and communication
with the student. It may be disclosed to other educational institutions, government departments and co-sponsoring
organizations, and, for those students who are members of
UMSU, it will be disclosed to the University of Manitoba Students’ Union. Information regarding graduation and awards
may be made public. Upon graduation, the student’s name, address, and diploma/degree information will be provided
to and maintained by the Alumni Records department in order to assist in the University’s advancement and
development efforts. It is protected by the Protection of Privacy provisions of The Freedom of Information and
Protection of Privacy Act. If you have any questions about the collection of the information, contact the FIPPA/PHIA
Coordinator’s Office, University of Manitoba Archives & Special Collections, 331 Elizabeth Dafoe Library, Winnipeg,
MB, Canada, R3T 2N2 (telephone 204-474-8339)

Notice Regarding Disclosure of Personal Information to Statistics Canada

The Federal Statistics Act provides the legal authority for Statistics Canada to obtain access to personal information
held by educational institutions. The information may be used only for statistical purposes, and the confidentiality
provisions of the Statistics Act prevent the information from being released in any way that would identify a student.

At any time, students who do not wish to have their information used are able to ask statistics Canada to remove their
identifying information from the national database.
 -8-

G. REFERENCES:

To the Applicant: Your application will not be reviewed unless we receive written
recommendations from two people who have current knowledge of you. Use the reference forms
included in this application. Give them to the referees of your choice.

IT IS YOUR RESPONSIBILITY TO ENSURE THAT YOUR REFERENCES REACH US

BY THE APPLICATION DEADLINE.

It is important that the people you choose as references are able to comment on your abilities for
social work. Suggested choices would be social services workers, teachers, other professionals,
and employers who have had close contact with you, or someone who has known you well for at
least the last two years. PLEASE DO NOT USE RELATIVES.

The people you choose should complete the attached forms and return them directly to us.

Please list below the names, addresses, phone numbers, positions, and organizations of your two
references. These people, in addition to previous employers, may be personally contacted for the
purpose of obtaining additional information or clarification.

References:

1. Name _________________________________________________________________
Address_________________________________________________________________
_____________________________________Postal Code__________________
Phone _____________________________________
Position & Organization __________________________________________________
Relationship to Applicant _________________________________________________

2. Name _________________________________________________________________
Address_________________________________________________________________
_____________________________________Postal Code__________________
Phone _____________________________________
Position & Organization __________________________________________________
Relationship to Applicant _________________________________________________

PLEASE KEEP THIS PAGE WITH APPLICATION

-9-
 UNIVERSITY OF MANITOBA
NORTHERN SOCIAL WORK PROGRAM
CONFIDENTIAL REPORT FORM #1

You have been asked to be a reference for an applicant to the Northern Social Work ACCESS
Program. Please complete this form and mail it directly to Student Records, Faculty of Social
Work, 3 Station Road, Thompson, MB. R8N 0N3.

DEADLINE: References are to be received before or on the deadline date.

References are used to assist the Northern Bachelor of Social Work ACCESS Program select
students for entry to the Bachelor of Social Work Program. The information supplied by you will
remain confidential.

The name of the applicant for whom you are a reference ____________________________
_____________________________________________________________________________
Your name ___________________________________________________________________
Organization (if any) ___________________________________________________________
Your relationship to the applicant ________________________________________________
How long have you known the applicant__________________________________________
Please comment on the applicant’s:

a) Awareness of and concern about social issues

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________ b)
Ability to relate to others
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________ c)
Communication skills (written and verbal)
________________________________________________________________________
________________________________________________________________________ d)
Critical thinking and judgement
 ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

e) Initiative, creativity, resourcefulness

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
f) Ability to work under stress or in ambiguous situations
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
g) Honesty, integrity
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Please comment on any limitations that might affect this person in a university degree program and
this career.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Other comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature of Referee ______________________________ Phone # _____________________
 UNIVERSITY OF MANITOBA
NORTHERN SOCIAL WORK PROGRAM
CONFIDENTIAL REPORT FORM #2

You have been asked to be a reference for an applicant to the Northern Social Work ACCESS
Program. Please complete this form and mail it directly to Student Records, Faculty of Social
Work, 3 Station Road, Thompson, MB. R8N 0N3.

DEADLINE: References are to be received before or on the deadline date.

References are used to assist the Northern Bachelor of Social Work ACCESS Program select
students for entry to the Bachelor of Social Work Program. The information supplied by you will
remain confidential.

The name of the applicant for whom you are a reference ____________________________
_____________________________________________________________________________
Your name ___________________________________________________________________
Organization (if any) ___________________________________________________________
Your relationship to the applicant ________________________________________________
How long have you known the applicant__________________________________________
Please comment on the applicant’s:

a) Awareness of and concern about social issues

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________ b)
Ability to relate to others
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________ c)
Communication skills (written and verbal)
________________________________________________________________________
________________________________________________________________________ d)
Critical thinking and judgement
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
e) Initiative, creativity, resourcefulness
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
f) Ability to work under stress or in ambiguous situations
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
g) Honesty, integrity
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please comment on any limitations that might affect this person in a university degree program and
this career.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Other comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Signature of Referee ______________________________ Phone # _____________________

GUIDE TO COMPLETING APPLICATION FORM

If you have or will have completed 30 credit hours and are in good standing, please call 204-677-1454
or email [email protected] or No Charge Dial 1-866-237-5509 ; you may need to
complete a different application form.

• All questions are to be answered fully in the applicant’s own handwriting.

• Only complete applications will be considered. The five documents you must include with your
application are official school transcripts, autobiography, two reference forms and proof ofage.
A photocopy of your driver’s license, birth certificate or baptismal certificate is fine. Please note
original transcripts will be returned to you.

• This information is confidential and will be used to assess your eligibility and suitability for the
program.

• Return the completed application to: University of Manitoba

Northern Social Work Program
Attention: Student Records
3 Station Road
Thompson, Manitoba
R8N 0N3

Or scan to [email protected] (preferred method)

• If you have any questions about how to fill out any part of the application form, or if you are unable to
get all of the requested information, please call the Faculty of Social Work at 204-677-1454 or No
Charge Dial 1-866-237-5509.

The program and its’ Selection Committee will be making decisions based on the information that you
provide in your application form. Please take your time in completing the application form. We do not want
to deny someone an opportunity because we do not have enough information.

Information that you must provide to Student Records include:

• full name (while you were a student)

• date of birth
• school name and year attended
• grade level

School marks for Grade nine or lower will only be available from your former school. You should attempt to
send your school marks to the Program at the same time as the application form. If you cannot include your
marks with the application form, please explain why on the application form or contact the program.
Letter of Reference

It is important that the person who is completing the reference form about you knows something about the
Social Work Program, (length, location and type of training). Depending on who completes the form, they
might write about your school and/or work experience, skills, accomplishments or personal qualities. The
letter writer might also comment on what they think about your application to the Program. Two
Confidential Reference Forms are attached to the application form.

You should attempt to include your reference forms with your application form. If the reference forms are
sent separately, please indicate this on your application form. If your letter writers send their forms directly to
the Program, it would be important to remind them that the letters must be received before the application
deadline date.

The Autobiography

This is a very important part of your application. Please take your time in completing this part of the
application form.

The decisions that we have to make center around your academic, personal/social needs for support by the
Program. Your suitability to the area of training or study is also given some consideration. If relocation is
involved, it would be important that you write about your thoughts on relocation and previous experience in
living elsewhere. If you have a family, it is very important that you write about how your family will be
affected by the move and by your becoming a student. If you and your family have other concerns, it would
be important to write about these concerns in your autobiography.

Sometimes it is difficult to brag about big or small accomplishments. We encourage you to write about your
achievements, what you are proud of and what makes you special.

During the selection process, we take into consideration any work or volunteer experience an applicant may
have in any kind of social service area. While such experience is not required for admission into the
program, we see it as an indicator of interest, motivation and commitment to social work as a career.

Students may have some difficulty at first with the academic demands of university degree courses.
Supports have been built into the program to make the adjustment as easy as possible. Development of
reading and writing skills through upgrading courses prior to entry into the program also assist students in
meeting academic demands.