Fleming Registration Form Dual Credit ApplicationPlease complete the below fields:Ontario Education Number* Have you ever applied at Fleming or taken a course there?* Yes No If you answered Yes above, please provide your student number Name*Please include the first and last name as listed on your Birth Certificate. This name will be kept confidential if you provide a Preferred Name. First Middle Last Preferred NamePlease include your preferred name if it is different than your legal name. If your preferred name is the same as you legal name, you may leave this field blank. Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Prefer to Specify Prefer Not to Disclose Address*In the fields below, enter your complete address. Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Main Phone*Secondary PhoneEmail* Secondary School & College Course InformationName of Secondary School* Name of School Board* Fleming Course Title* Course Code* Section* Release of Information*Fleming College will use registration information for academic research purposes as approved by the College Applied Research Committee. Please indicate below if you agree to share your personal information for college approved academic research purpose only. Yes, I agree. No, I don't want my information to be shared for college approved academic research. Fleming College Consent and ReleaseI consent, that any photographs, digital images or files, audio or videotape taken by College personnel or by individuals contracted by the College may used for promotional purposes which includes College publications, broadcasts, website and / or use by the public media when that media requires my information in connection with the printing / broadcasting / web posting of College-related publicity. The legal authority for the collection of this information is the Ministry of Colleges and Universities Act. R.S.O. 1980, C.272 If you have any questions about the collection, use and disclosure of this information, please contact the Manager, Dual Credit Operations, at 705 749-5520. Yes, I consent No, I do no consent Application Submission*I understand the commitment that I am making to the Dual Credit/School College Work Initiative (SCWI) program and that I must consent to the following in order to submit an application and participate in the program: The information on this form is collected under the legal authority of the Ontario Colleges of Applied Arts and Technology Act, 2002, Ontario Regulation 34/03 and in accordance with Section 39(2) of the Freedom of Information and Protection of Privacy Act, 1990. The information is used for the administrative, academic and statistical purposes of Fleming College to administer the School College Work Initiative specifically as outlined below: - Registration and access to the college Student Information System (myCampus); - Access to the College Learning Management System; - Tracking and reporting your grades, student success data and demographic data to your Secondary School, your School Board, Fleming College administration, the Ministry of Education and the Ministry of Advanced Education and Skills Development. - Sharing Individual Education Plan (IEP) information if required to access appropriate accommodation for learning. I hereby consent and authorize the release and disclosure of the above stated information upon registering for the dual credit program. PhoneThis field is for validation purposes and should be left unchanged.