Program Applying For:

First Name:

Last Name:

Mailing Address:

City:

Province:

Postal Code:

Home Telephone:

Cell Phone:

Work Telephone:

work Fax:

Email:


Language(s) fluent:

Language(s) written:


Date of Birth:

Social Insurance Number:




In Case of Emergency Contact:

Relationship:


Telephone:




Where did you hear about the AEI?




Education Counselor:


Telephone:


Sponsorship Letter Submitted:   Yes     No

OSAP:   Yes     No

First Nation Name:


Employer and Organizationís Name:


Your role within Organization:




Do you have a current Standard First Aid Certificate?   Yes     No

Do you have a current CPR+Peds Certificate?   Yes     No


Identify any health related concerns that you would like us to know about (i.e. diabetes):


These certificates only apply to specific programs that are required prior to the first field placement / field practicum.



Secondary School

Last grade completed:


Year completed:


Name of school:


Transcripts Submitted:   Yes     No



Post Secondary

Name of College/University:


Program of Study:


Year(s) Attended:


Graduate:   Yes     No

Official Transcripts Submitted:   Yes     No



Employment Experience (last three years)

1. Name of Organization:

1. Position Held:

1. Duration of Employment:


2. Name of Organization:

2. Position Held:

2. Duration of Employment:


3. Name of Organization:

3. Position Held:

3. Duration of Employment:


4. Name of Organization:

4. Position Held:

4. Duration of Employment:




Briefly describe any experience you feel is relevant to your participation in the program: (Volunteer work, committees, community activities, etc.)



Some programs include fieldwork placements that require a Criminal Records check. This check is the responsibility of the student to obtain prior to your enrollment into the program. If this is relevant to the program you are registering for, do you have any concerns relating to this?





Indicate three character references:

1. Name:

1. Position:

1. Telephone:


2. Name:

2. Position:

2. Telephone:


3. Name:

3. Position:

3. Telephone:




Self-Assessment Questionnaire

The following questions enable the AEI to determine program admission. Each question was designed to assist applicants to explore their strengths and other areas that may need further exploration prior to enrolling into their program of study

Identify your support network:



How will you utilize this support network while you are enrolled in your program of study and while you are attending the on-campus sessions?



What arrangements will you make with your employer and co-workers while you are away from work environment attending classes and mandatory program field placements or volunteer?



Please identify any personal, family, or work related difficulties that you feel may interfere with your ability to complete your program of study?



How do you deal with stress?





Self-Exploration

The full-time distance delivery program is a unique format that allows students to remain within their communities while studying towards their post-secondary diploma. Students attend two-week on-campus theory based sessions twice a semester for five semesters. These sessions are condensed learning environments, which are mandatory for each enrollee.

The following four writing exercises will help you to explore your own strengths and attributes.

Please describe why you would like to pursue this field of study?



What personal or professional experiences have you been involved in that may be helpful to you while you are enrolled in your program of study program? Why would these experiences be helpful?



What personal or professional strengths and attributes do you have that would help you to succeed in this type of program delivery format?




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