My Enrolment Status, My Presence in Class and My Final Results

By registering for this course, I consent to the Division de l’éducation permanente’s sharing information with WRHA French Language Services about

my enrolment status, my presence in class and my final results.

Is French your first language? Yes No

New Student: Unknown level – requiring placement test

Former Student – Please check the last level completed at USB.

Beg. 1Beg. 2Beg.3Beg. 4

Int. 1 Int. 2 Int. 3 Int. 4 Avancé Perf.

Session: Fall WinterSpringYear

Sex: M FUSB Student Number:

(for office use only)

Registrant’s Information

Last nameFirst name

Home address

City/ProvincePostal Code

Phone (home)Phone (work)Phone (cell)

Home emailWork email

May we send you email messages about workshops offered by WRHA French Language Services? Yes No

Can USB send you email messages about courses offered by the Continuing Education Division? Yes No

Availability: indicate your top 3 choices of days that best suit your schedule

1st2nd3rd

Return completed application form with deposit fee to the address above. Spaces are limited. Registration must be approved by WRHA FLS.DO NOT SEND THIS FORM DIRECTLY TO USB.

Method of payment$50 fee to be incurred by the student.(Includes handbook)

Cheque (payable to USB) Visa Mastercard

Post-dated cheques will not be accepted. Any student who tenders a cheque not honoured by the financial institution will be charged a fee of $30.

Credit card numberExpiry Date

Name of credit card holder

______

Signature

(Credit card information destroyed after receipt issued) Personal information is being collected under the authority of the Université de Saint-Boniface Act. It will be used for the purposes of administering the Français oral program. It will not be used or disclosed for other purposes, unless permitted by the Freedom of information and Protection of Privacy Act (FIPPA). If you have any questions about the collection of your personal information contact the FIPPA/PHIA Coordinator’s Office (204-237-1818, ext. 398). Service des archives de l’Université de Saint-Boniface 200 De la Cathédrale Avenue, Winnipeg, MB R2H 0H7.

Course confirmations will be sent by email

Only one email address is required but both are useful to ensure you receive messages as soon as possible. If you do not use email, we will confirm your registration by phone.

Language Proficiency

Have you any knowledge of French? Yes No

Did you study French in school? Elementary Secondary level Post-secondary

Do you have supplemental French Language Training? Yes No

When and where?

If known, which level are you currently registering for?

Your evaluation of language proficiency (check one):

Can’t speak French at all (Call 204-237-2889 to discuss preliminary training options)

Can speak a few memorized sentences (Call 204-237-2889 to discuss preliminary training options)

Can speak a few memorized sentences

Can talk on very general topics – weather etc.

Can talk on a variety of topics but lack spontaneity and accuracy

Can talk on a variety of topics with ease

Can handle uncomplicated work related matters

Can have in depth conversations on work related matters

If selected, you will receive a phone call in French from a representative of l’Université de Saint-Boniface to determine your course level.

Please note that with the exception of the Perfectionnement level, all classes focus primarily on spoken French.

______

Position Details

Place of Employment (Please clearly indicate)Program/Service:

Facility/agency

Current Position:

If you hold multiple positions please indicate:

Your position is: permanent term: if so, since when full-time part-time If PT, EFT

Your position is designated bilingual Yes No

Length of service with the WRHA/health care system (please check one)

1 - 3 years 5 - 10 years 15 - 20 years

3 - 5 years 10 - 15 years 20+ years

Is your position designated bilingual? Yes No (If yes, you should be applying for Program 1)

Are you in direct contact with:

Patients Residents External Clients Public Media None

How often would you have occasion to speak with francophone patients, clients, residents and the public? (Check one)

Once a day Several times a day Once a week

Several times a week Occasionally but in a key role.Please explain:

Name of your Manager / Supervisor: Phone Number:

As spaces are limited, please provide any further information that may be helpful in assessing your application.