Co-curricular Programme: Application for Special Admission

Co-curricular Programme: Application for Special Admission
SECTION A- Personal Information
1. Name

First NameLast Name
2. (a) Former name (if applicable)
(b) Type of former name

Maiden(Prior to) Deed Poll
3. Have you previously applied to UWI?

YesNo
4. Have you previously been a student at the UWI?

YesNo
5. If answer to question 4 is yes, please state the following: (a) Identification Number
(b) From(year) (c) To (year)
(d) Campus
(e) Programme
6. Permanent address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
7. Mailing address (if different from Permanent address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
8. Home/Permanent Phone
Please enter a valid phone number.Format: (000) 000-0000.
9. Mailing Address Phone
Please enter a valid phone number.Format: (000) 000-0000.
10. Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
11. Work Phone
12. Fax number
13. Email address
example@example.com
14. Gender

MaleFemale
15. Date of birth
16. National ID/Driver's Permit number
17. Marital status

SingleMarriedCommon LawLegally SeparatedDivorcedWidowed
18. Country of Birth/National of
19. Country of Citizenship
20. (a) Country of Residence
(b) Duration (years)
21. (a) Do you have a disability? (This information is needed in case special facilities are required)

YesNo
(b) If yes, please specify.
SECTION B- Courses
22. Please choose the course(s) you wish to take at the UWI:

First Aid, CPR, AEDMeditation for Holistic HealthMicrosoft Excel 2019Microsoft PowerPoint 2019Microsoft Office Word 2019Public Speaking & Voice TrainingIntroduction to Sign LanguageThe Basics of Steel Pan
23. Please choose alternative courses in the event that the courses you chose above are unavailable:

First Aid, CPR, AEDMeditation for Holistic HealthMicrosoft Excel 2019Microsoft PowerPoint 2019Microsoft Office Word 2019Public Speaking & Voice TrainingIntroduction to Sign LanguageThe Basics of Steel Pan
24. (a) Are you a UWI staff member?

YesNo
(b) If yes, state: Staff Identification Number
(c) Campus:
(d) Department:
25. How did you obtain information about the UWI Co-curricular courses?

UWI AlumniSchool/College FairSchool VisitEmployerInternetMediaOther
SECTION C- Academic Record
26. Please list any short courses you have taken, and/or any computer competencies you possess, beginning with the most recent.
Institution name, from (mm/yy) to (mm/yy), Name of course.
SECTION D- Emergency Contact Information

Please indicate information for an emergency contact person
27. (a) Name

First NameLast Name
(b) Relationship to Applicant
(c) Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(d) Emergency Contact Home/Permanent Phone
Please enter a valid phone number.Format: (000) 000-0000.
(e) Emergency Contact Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
(f) Emergency Contact Work Phone
SECTION E- Declaration
I hereby certify that I have read and understood the instructions and the information necessary for completing this application and that all statements made are true and complete. I accept that the University reserves the right to reject this application if the information submitted in its support is based in whole or in part on deception or fraud.
YesNo
Date (dd/mm/yyyy)
FOR OFFICIAL USE ONLY
Documents Received

Proof of paymentLetter from Head of Department (UWI Staff only)
State of approval

ApprovedNot approved
Signature of University Officer
Date (dd/mm/yyyy)
Comments
Should be Empty:

Co-curricular Programme: Application for Special Admission

SECTION A- Personal Information

SECTION B- Courses

SECTION C- Academic Record

SECTION D- Emergency Contact Information

SECTION E- Declaration

FOR OFFICIAL USE ONLY