WIXLIB

uKwaziSCHOOL OF NURSINGYOUR HEALTH CARE EDUCATORSAPPLICATION FORMENQUIRIES ROODEPOORT CAMPUSDirect all enquiries about your application to 011760-3098 or bella@ukwazi.co.zaENQUIRIES POTCHEFSTROOM CAMPUSDirect all enquiries about your application to 018297-6532 or email to betsie@ukwazi.co.zaDELIVERY ADDRESS ROODEPOORTCAMPUSHorison Office Park, 6 Kingfisher St, Horizon Park,Roodepoortbe made telephonically or by email to thedetails as set out under ENQUIRIES2An application fee of R2500-00 is payable – thebanking details appear in the InformationBrochure. Please ensure that the correctbanking details are used of the campus towhich application is made. Proof of paymentmust accompany your payment without whichyour application will not be processed.31st Floor, Standard Bank Building, cor Walter Sisulust & Retief St, PotchefstroomVERY IMPORTANT Please read the instructions carefully andcomplete all applicable sections Only one application form is to besubmitted Please allow 10 days before checking onthe status of your application1ADMISSION REQUIREMENTSCOMMUNICATION TO APPLICANTSYou will receive separate email and / or SMScommunications regarding the outcome ofyour application. Please therefore ensurethat your email and cellphone contact detailsare correctly given herein. PLEASE INFORMUS IMMEDIATELY OF ANY CHANGES TOYOUR EMAIL ADDRESS / CELLPHONENUMBER.DELIVERY ADDRESS POTCHEFSTROOMCAMPUSINSTRUCTIONS FOR COMPLETING THEFORMAPPLICATION FEES4ACADEMIC DOCUMENTSThe following documents must be submittedwith your application – copies of documentsto be certified.Please consult the INFORMATION BROCHUREobtainable from Administration – requests canukw p & p – STUD001-002 – application formVersion 1/2019Page 1 of 9

4.1 Applicants currently studying towards a South African Grade 12Documents RequiredSouth African Identity documentProof of payment of Application Fee4.2 Applicants having already completed a South African Grade 12Documents RequiredFinal Grade 12 statement of symbolsNational Senior Certificate or Senior Certificate (prior to 2008) or IEB certificate orSACAIHigher education qualification if obtained at another higher education institutionAcademic record and certificate of conduct if registered / completed at another highereducation institutionProof of payment of application fee4.2 International ApplicantsDocuments RequiredPassportStudy permit / asylum certificateInternational school-leaving statement of symbolsInternational qualification certificate with SAQA evaluation documentAcademic record and certificate of conduct if registered / completed at another highereducation institution in South AfricaProof of payment of application fee5APPLICATION FEE An application fee of R2 500-00 is payable without which an application will not be considered. Acopy of the deposit slip must accompany this Application Form Payment must be made into the following account:ROODEPOORT CAMPUSBANKFIRST NATIONAL BANKNAME OF ACCOUNTUKWAZI SCHOOL OF NURSINGACCOUNT NOBRANCH NO62030583133251-141REFERENCESURNAME AND INITIALS AS WELL AS CELLPHONE NOukw p & p – STUD001-002 – application formVersion 1/2019Page 2 of 9

POTCHEFSTROOM CAMPUS BANKFIRST NATIONAL BANKNAME OF ACCOUNTUKWAZI SCHOOL OF NURSINGACCOUNT NO62073434608BRANCH NOREFERENCE251-141SURNAME AND INITIALS AS WELL AS CELLPHONE NOPlease submit only a copy of your deposit slip and retain the original as proof of paymentACADEMIC APPLICATIONACONSENT TO COLLECT AND PROCESS PERSONAL INFORMATION (POPI)I, the undersigned applicant (duly assisted by a competent person where I am under the age of 18), herebyagree to the processing of my personal information for purposes of applying to UKWAZI SCHOOL OF NURSING(“the School”) with its main campus at 6 Kingfisher St, Horizon Park, Roodepoort.The School is committed to protecting the applicant’s privacy and recognises that it needs to comply withstatutory requirements insofar as it is necessary to process the applicant’s personal information. The School isobliged in terms of section 18 of the Protection of Personal Information Act 4 of 2013, to inform you of thefollowing:i.The type of information that the School will collect and process includes any personal information thatcan identify you, your matriculation marks, national benchmark test scores and marks from othereducational institutions, including higher education institutions (if applicable).ii.The nature/category of the information that the School will process will relate to academicperformance indicators.iii. The purpose of processing the information will be to consider and determine admission to anyprogramme at the School.iv. The School will source the information from yourself, the Department of Basic Education, theDepartment of Higher Education and Training and any other educational institutions (whereapplicable).v.The School shall be entitled, where applicable, to transfer the information to a third-partycountry/organisation.vi. The School has a legal obligation to obtain such information for selection purposes in terms of theHigher Education Act 101 of 1997 (as amended) and the rules and regulations of the School.vii. Failure to consent to the processing of such information may compromise your admission.viii. You have the right to access and to amend any information processed by the School at any reasonabletime.ix. You have the right to direct any complaint regarding the processing of your information to the principalof the campus to which your application is submitted.Further to the above consent, I understand that my personal information is also protected in terms of section50 of the Electronic Communications and Transactions Act 25 of 2002 (ECT Act). In terms of section 51 of theECT Act, I hereby provide my express written permission to the School for the collection, collation, processingukw p & p – STUD001-002 – application formVersion 1/2019Page 3 of 9

and/or disclosure of any of my personal information, without prejudice to other legal grounds upon which theSchool is permitted or required to do so.Signature of ApplicantDateBDECLARATION AND SURETYSHIP BY PARENT, LEGAL GUARDIAN, THIRD PARTYIf you are under 18, your parent / legal guardian must make this declaration. If you are older than 18 and yourparent / legal guardian / third party (e.g. a family member, husband, etc) will be paying your fees, your parent /legal guardian / third party must make this declaration.TitleSurname of parent / guardian / third partyFirst names of parent / guardian / third partyArea /Country TelCodePostal addressLandline / cellphone numberIdentity number of parent / guardian / third partyPostal / zip codeI as parent / legal guardian agree and consent to the above declaration, undertakings, and indemnity by theapplicant. I consent to the applicant signing registration forms if admitted. I as parent / legal guardian / thirdparty hereby bind myself jointly and severally with the applicant as co-principal debtor for all amounts due bythe applicant to the School. I consent to the School holding and processing personal information supplied byme in this application (for purposes related to this application).Signature of parent / legal guardianDateNB: An applicant under the age of 18 must have this form signed by either of his / her parents. Where an applicant has noparents (e.g. they are deceased) the legal guardian must sign this form. If you do not have a parent or a legal guardian, aresponsible adult family member (next-of-kin) or other responsible adult who is prepared to make the declaration and theundertaking, must sign with you. The details of this person must be listed under the parent / guardian / third party sectionabove.ukw p & p – STUD001-002 – application formVersion 1/2019Page 4 of 9

CQUALIFICATION FOR WHICH APPLICATION IS M ADEThe year of study for which you are applyingSelect the qualification for which you are applying (please ensure that you meet the admission criteria)(tick theappropriate block):HIGHER CERTIFICATE IN AUXILIARY NURSINGtickDIPLOMA IN NURSINGtickDPERSONAL DETAILSSURNAME (as in your Identity document)FULL NAMESIDENTITY NUMBER / DATE OF BIRTHPASSPORT NUMBER (for foreign students)TITLEGENDERHOME LANGUAGE MR MALE MRS FEMALE MISSNATIONALITY SOUTH AFRICAN OTHER (name of country)RESIDENTIAL ADDRESSPOSTAL ADDRESSHOME PROVINCETELEPHONE: HOMEWORKCELLE-MAILukw p & p – STUD001-002 – application formVersion 1/2019Page 5 of 9

ESCHOOL LEAVING DETAILSi.Highest grade passed at school to dateGrade 11 / Prelim International School resultsYearGrade 12 / Final International School resultsYearNo mid-year grade 12 results are acceptedii.Particulars of school attendanceName of School attendedSchool postal addressPostal codeSchool telephone noTown & ProvinceFSCHOOL-LEAVING SUBJECTS (only applicable to applicants currently in grade 12)Subjectsukw p & p – STUD001-002 – application formAdmissionPoint ScoreFinal Grade 11 Results (%) / PreliminaryInternational School ResultsVersion 1/2019Page 6 of 9

GHIGHER EDUCATION QUALIFICATIONSProvide full details of studies at higher education institutions(s) as indicated above, if applicable. In the event ofa discontinuation of studies, indicate the date of cancellation.Year fromHYear toHigher EducationInstitutionField of StudyResult (e.g. cancelled, failed,qualification obtained)DISABILITY PARTICULARS (IF ANY)Do you have a disability? Please indicate in either of the boxes below.YESNOIf “YES” please indicate the nature thereof under the categories listed belowPhysicalVisualLearningHearingCerebral PalsyBlindnessDyslexiaDeafnessParaplegicLow visionADD / ADHDPartial HearingQuadriplegicPartially sightedDyscalculiaImpaired mobilitySpeechSpeech impairmentPlease provide in detail the nature of your disability e.g. use of wheelchair, crutches, etc:Please note: selection is based on academic achievement and not on your disability. The programmes we offerhowever put great physical demands on students and the School may refuse an application where it is of theopinion that an applicant will be unable to meet the physical demands of the programme for which applicationukw p & p – STUD001-002 – application formVersion 1/2019Page 7 of 9