International Student Application Form

For Office Use:
Student #:
Public Trust #:
NSI#
International Student Application Form 2016
Family Name:
Other Name(s):
Name (know as):
Tick the appropriate boxes: Male
Female
Married
Date of Birth:
Month
Year
Day
Single
Occupation:
Country of Citizenship:
Religion:
Contact Address:
Telephone Numbers
Day:
Night:
Email Address
Proposed Programme (Tick the appropriate box):
Certificate in Outdoor Adventure Skills and Leadership
Diploma in Outdoor Recreation (Instruction)
Level of English
Or
TOEFL Score
IELTS Score
Date taken
Date taken
Or other internationally recognised English test.
Please provide details
I have not taken an internationally recognised test of English:
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Hillary Outdoors
Education Centres
Initial Application Questionnaire 2016
This form may be completed and returned electronically, and signed at a later stage.
Phone:
Private Bag 37
Turangi, 3353
New Zealand
Email:
Website:
07 386 5511
[email protected]
www.hillaryoutdoors.co.nz
Welcome to Hillary Outdoors. Please answer the following questions, to the best of your ability. There
are no right or wrong answers to these questions. The purpose is to give us an insight into your prior
learning as it relates to this programme.
A
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PERSONAL DETAILS
Print your
full legal
name:
Family Name
Given Name(s)
Preferred first name:
2
Course applied for:
3
Nationality: (attach a copy of ID,
drivers license or passport, with visa if
necessary)
If you are from New Zealand, do you
identify as New Zealand Māori?
Age:
B
4
Date of Birth:
CONTACT DETAILS
Address and
contact details:
Phone:
Home Address:
Postal Address: (if different from home address)
Mobile:
Email:
2
C
5
NSN
Very important – this number has to be submitted with all applications
National Student Number (NSN): ____________________________________
Your NSN number is allocated to you by your school. If you do not have it please contact your school
or the NZQA Helpdesk on 0800 697 296 or [email protected]
D
QUESTIONNAIRE
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In what way have your experiences so far equipped you for this particular course?
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What special strengths will you bring to this course?
8
What are your weaknesses?
3
9
What interests you about this course and how does it fit into your future plans?
10
How well do you communicate with and relate to people?
11
What clubs/organisations do you belong to and participate regularly with?
12
List your hobbies and interests.
13
Describe your ability as a swimmer (fresh cold water) – tick one box only:
Strong
Water confident
Not water confident.
4
14
E
15
What do you do to keep physically fit?
ACADEMIC INFORMATION
Secondary
School:
What was the name of the last
secondary school you
attended? State “overseas”, if
applicable.
What was your last year at secondary school?
What is the highest level of achievement you hold from a secondary school? Your highest
achievement may be a “traditional” award such as School Certificate, or you may have achieved a
number of credits or a National Certificate at a certain level on the National Qualifications
Framework. Your NZQA Record of Achievement shows you how many credits you have. Tick only
one box.
No formal secondary qualifications
00
14 or more credits at any level
11
NCEA Level 1 or School Certificate
12
NCEA Level 2 or 6th Form Certificate
13
University Entrance
14
NCEA Level 3 or Bursary or Scholarship
15
Overseas qualification (includes International Baccalaureate & Cambridge Exams) *
09
Other *
98
Not known
99
* Please specify if “Overseas qualification” or “Other”.
________________________________________________________________________
F
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TERTIARY EDUCATION
If you have studied at other Tertiary Institutions please enter the details in the table below.
Year of
Study
Name of Institution
Name of course
Number
of years
Completed
yes/no
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G
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EMPLOYMENT HISTORY
Please complete the table below for your most recent employment. Of particular interest is volunteer or paid
work that relates to the outdoors.
Dates
H
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Name of employer
Type of work
OFFENCES
Have you been convicted of a criminal offence within the past 10 years, or are you currently being charged
with a criminal offence?
Yes / No (please circle)
If yes, please give details:
Successful applicants will be required to complete a Police Check as this course involves contact with young
people. Unrelated offences may not preclude you from being accepted.
I
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REFEREES
Please provide the names and contact details for two referees who may be contacted by us.
Name
Relationship to Referee:
Phone:
Mobile:
Email:
Name
Relationship to Referee”
Phone:
Mobile:
Email:
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Please help Hillary Outdoors to advertise in the right places by letting us know how you heard about this course:
How would you be planning to pay the course fees?
Student Loan / Private Payment (please circle)
This form may be completed and returned electronically, and signed at a later stage.
Declaration – I declare that to the best of my knowledge all the information supplied on, and with, this application
form is true and complete, I agree to abide by the conditions described above, and I consent to the disclosure of
personal information as described above.
___________________________________________________
Signature
______/_____/______
Date
 Please make sure that you sign your application form above 
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Pursuit
Approximate
number of
days spent
involved in
pursuit
Competency level reached e.g.
beginner/ intermediate/
advanced
With whom did you
participate?
Location, where mainly have
you been involved in this
pursuit?
Any formal training? (state
with whom)
Tramping:
Day tramps
Multi-day tramps
Mountaineering:
Rock Climbing:
Natural rock
Indoor walls
Can you lead? Yes/No
Kayaking:
Kayaking
Flat
water
Rivers
Can you roll a kayak? Yes / No
Climbing grade?
Leading grade?
If so what side and type?
Grade of river:
Sea Kayaking:
Sea Kayaking:
Rafting:
Rafting:
Caving:
Caving:
Instructing:
Instructing groups
Assistant instructing groups
Observing groups
Other: (Please specify)
Driving: (Circle one)
Learners
Restricted
Full Car
Other: (Please specify)
Please complete the table above with as much information as possible, use extra paper if required.
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Code:
The Hillary Outdoors Education Centres has agreed to observe and be bound by the Code of Practice for the Pastoral Care of
International Students published by the Minister of Education. Copies of the code are available on request from this institution or from
the New Zealand Ministry of Education website at http://www.minedu.govt.nz/goto/international
Immigration:
Full details of visa and permit requirements, advice on rights to employment in New Zealand while studying, and reporting
requirements are available from the new Zealand Immigration Service, and can be viewed on their website at
http://www.immigration.govt.nz
Eligibility for Health Services:
Most international students are not entitled to publicly funded health services while in New Zealand. If you receive medical treatment
during your visit, you may be liable for the full cost of the treatment. Full details on entitlements to publicly funded health services are
available through the Ministry of Health and can be viewed on their website at http://www.moh.govt.nz
Accident Insurance:
The Accident Compensation Corporation provides accident insurance for all New Zealand citizens, residents and temporary visitors to
New Zealand, but you may still be liable for all other medical related costs. Further information can be viewed on the ACC website at
http://www.acc.co.nz
Medical and Travel Insurance:
International students must have appropriate and current medical and travel insurance while studying in New Zealand. NB Students
must provide evidence of appropriate and current medical and travel insurance. This insurance must cover the full length of time spent
in New Zealand. An overseas Insurance Policy will only be accepted if it is accompanied with an English translation. Hillary Outdoors will
keep a record of the Insurance Policy number and the type of cover provided.
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Conditions of Acceptance:
If your application is accepted you will receive from Hillary Outdoors a letter offering a place on the course. You are then required to
accept this offer by paying a minimum deposit of 10% of the course fee. This must be paid within 7 days of written confirmation of
acceptance on the course to guarantee you a place on the course. The payments should be made in New Zealand dollars through a New
Zealand registered bank or by bank draft.
You are then required to make visa applications, fees must be paid in full before student visas or permits are issued by NZ Immigration.
Refunds: The final date for withdrawal from the Certificate in Outdoor Education course for International Students is up until the end
of the fifth day of the course where students are entitled to a refund of 75% of total fees paid.
The final date for withdrawal from the Certificate in Outdoor Recreation Assistant Leadership or Leadership course for International
Students is up until the end of the eighth day of the course where students are entitled to a full refund less $500.00 or 10% of the
course fee whichever is the lesser.
Withdrawal from the courses after these withdrawal periods does not result in any refund.
Course fees will be refunded in full, without deductions, only if you are refused a visa by New Zealand Immigration Authorities and if
your cancellation is received at least four weeks before the commencement of the course.
If the information you give in your application regarding your age, outdoor skills and experience or English language ability has been
falsified Hillary Outdoors reserves the right to terminate your place on the course.
Declaration by Applicant:
I have read and understood the above and agree that the facts stated by me in my application are true and correct.
Signature of Applicant:
Date:
Day
Month
Year
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