Post Secondary Student Support Program
P.O. Box 216, Pic River First Nation
Heron Bay, ON P0T 1R0
(807) 229-0188 Fax: (807) 229-1944 or 229-3727
Application for Educational
Assistance
(Confidential When Complete)
Please complete all 6
pages of the application
Student Application Form - Revised May 2013
Application Date: Y______ M______ D______
Birth Date Y_____ M_____ D______
Band Number: 1920_ _ _ _ _
S.I.N. # _ _ _ _ _ _ _ _ _
Have you received Post Secondary funding before?____________
If yes when:_____________________
(If you are a continuing student as defined in the post secondary student policy then please fill out the
simplified continuing student form which can be found on the website at www.picriver.com)
Prior Post Secondary Funding: Attended from M_______ Y_______ to M______ Y______
Program _______________________________________________
Institute:_______________________________________________
Did you successfully complete this post secondary program?: ______________________________
Surname: _____________________________ Given Name(s): ______________________________
Primary Residence: _____________________________________________________________________
Town & Province: _____________________________ Postal Code: __________________________
Telephone: ________________________________
Dependents: ______
Email: ________________________________
Ages: ____________________ (refer to Post Secondary policy for definition)
Are you a student with special needs? Yes ____ No _____ (most recent IPRC needs to be included)
Under the following:
_____ behavior
_____ communication
_____intellectual _____ physical
_____ multiple
If yes, what additional supports and costs do you require: ___________________________________
Are you presently employed? Yes ____ No _____
If you are presently employed are you working full time _____ or part time _____? If you are working part
time how many hours per week do you average? ______ hours per week. (Part time employment is
defined as 21 hours or less per week).
List other forms of funding while attending school
April 2013
Please describe your past or present involvement/participation/contribution with the Pic River First Nation:
Please describe your lineage and connection (relatives, blood ties) to the Pic River First Nation:
How do you envision your educational goals/accomplishments positively impacting the capacity building
efforts of the Pic River First Nation?
Have you read the post secondary student support policy? Yes _____ No _____
Do you fully understand and agree to the terms of the student support policy?
Yes ____ No ____
If your application is approved for funding you will be required to, “give back” to the community of Pic River,
the equivalent of 35 work hours per year of continued funding. Are you in agreement with this stipulation?
Yes _______ No _______
April 2013
Education Plan
Attendance: Full Time ___ Part time___
Type of Program: Entrance Program __ College __ University Diploma ___ B.A. __ M.A.__ PHD __
Program Name__________________________________ Program Length (years): 1 2 3 4
Institution:_____________________________________ Location:________________________________
Date of Graduation: Y_____ M_____ D_____ Current Year of Study: Year _______ of _________
Institutional Acceptance: Final ___ Continued ___ Conditional ___
Training Dates for this academic Year: Y______M______ D______
to Y______ M______ D______
After graduation from your approved program, do you plan on continuing? Yes _____
No _____
Long term goal/desired employment:
____________________________________________________________________________________
Year 1
Courses Required
Year 2
Courses Required
Diploma/Degree Checklist
Year 3
Courses Required
Year 4
Courses Required
(Verification will be compared to student’s timetable)
Expected Academic Costs
ACADEMIC YEAR 20___/20____
TUITION
BOOKS/SUPPLIES
LIVING ALLOWANCE
TRAVEL
GRAND TOTAL
April 2013
Please complete the Following Information: This information is part of your application for
funding. If not completed, application will be returned to applicant for completion.
Last Education Completed: _______________________________ Year________________
High School Graduate: Yes____ No____ Last Year Completed: _____________________
Present Grade, Course or Program Attending: ___________________________________________
Expected Date of Graduation: ________________________________________________________
Institute Name and Location: _________________________________________________________
Authorization
I have read and agree to the conditions of this financial agreement
_______________________________________
Student’s Signature
______________________
Date
_______________________________________
Administrator’s Signature /Authorizing
______________________
Date
For Office Use Only
Recommended ____ Not Recommended ____ Funding Conditional ____
Priority ______
Allowance Category_____ $____________ per month
PRFN Acc’t Number:__________________
Student Number(institute):_________________
Letter of Acceptance received: Yes ____ No ____
Transcript: Yes ____ No ____
April 2013
Pic River Post Secondary Student Support Program
Institute: ______________________________________________________________
Program: _______________________________________________________________
Academic Year:
20_______ / 20________
Authorization to Release Information
As a student sponsored by Pic River First Nation, I hereby authorize the above named post
secondary institute to release information, transcripts, attendance records and other
information pertaining to my academic progress to the above named sponsoring agency.
I also authorize Pic River First Nation to exchange information with the post secondary
institute as it pertains to my academic progress.
Student Name:
______________________________________________________
Student Address:
______________________________________________________
______________________________________________________
______________________________________________________
Student Number:
______________________________________________________
____________________________________________
Student Signature:
____________________________________________
Date:
April 2013
STUDENT AGREEMENT
I, ___________________________________________ as a post secondary student sponsored by the Pic River
First Nation I agree:
a)
To ensure that all times I am enrolled in sufficient courses to be considered a full time student as
described in Pic River’s Student Policy;
b)
That if I withdraw, without authorization from the Post Secondary Program Administrator, from the
course/program before completion of the semester, that the Pic River First Nation will NOT consider my
application for one complete calendar year;
c)
To return any money (living allowance, book allowances) issued to me after I have withdrawn without
authorization from the Program Administrator. I understand that I will no longer be eligible for
sponsorship until this money is returned or agreed arrangements have been made and this will result in
an overpayment assigned to my student file;
d)
That I will provide the Program Administrator with the documents requested, especially a letter of
acceptance from the institution that I am attending prior to living allowances being issued;
e)
That I will provide the Program Administrator with copies of mid-term and final grades as requested. I
understand that if I do not comply, my living allowance will be withheld;
f)
That I will provide the student support office with official transcripts every year that I am being
sponsored in my program.
g)
To abide by the policies applicable to the Post Secondary Program as outlined in the student manual;
h)
To attend classes on a regular basis and complete my homework and assignments when requested;
i)
To maintain the minimal grade point average for continuing in my program of study;
j)
To contact the Program Administrator or Education Director if I encounter any problems or wish to
change any course on a school program or if I am considering a program change. I understand that a
program change will only be considered by the Program Administrator or the Education Director in my
first year of academic studies.
k)
That I will claim as dependants only those whom I am legally responsible for and understand I will
receive support funding only after PRFN has received all pertinent documentation;
l)
I will voluntarily submit written confirmation of any changes in my dependants, location or program of
studies;
m)
To allow the institution that I am attending to release my grades to Pic River First Nation;
n)
To keep all receipts for books and supplies. Book allowances are included in my September allowance.
Supplements will be considered once receipts are received and will be dependant upon the availability
of funds. Computer purchase plan is available and is dependant upon the availability of funds.
o)
I will follow any other contract agreements made between the Program Administrator and myself.
SIGNED:
_______________________________
________________________________
DATE:
_______________________________
________________________________
(Student)
(Post Secondary Program Administrator)
April 2013