Pr 02 Form – Fill Out and Use This PDF

OPEN DISTANCE LEARNING

PR 02

REGISTRATION: WORK INTEGRATED LEARNING

Dear Principal

Thank you very much for receiving a prospective North-West University (NWU) Open Distance Learning Student at your school for work-integrated-learning (WIL) purposes. This student is applying to enrol as an open distance learning student.

We deem it a privilege to work in collaboration with schools in order to expose our students to optimal introductory experiences while in an authentic practical teaching environment. We thank you for accepting this student in your school and appreciate your willingness and commitment to involve the school and its personnel in the training of professional educators. If you have any questions please contact us.

This must be completed in full.

Attach this form to your application forms.

All fields are compulsory, except where email addresses are not available.

Please note that our preferred method of contact is through e-mail.

STUDENT INFORMATION:

NWU STUDENT

NUMBER*

OLG STUDENT

NUMBER*

*Office use only

Please complete in full and write clearly and neatly in block letters

ID NUMBER

CONTACT CENTRE NEAR

YOU:

PRIVATE OR

PROVIDE NAME OF BURSARY

TITLE

INITIALS

FULL NAME

PREFERRED NAME

SURNAME

CELLPHONE NUMBER

EMAIL ADDRESS

PREFERRED LANGUAGE

HOMETOWN

PROGRAMME/QUALIFICATION

GR R

PGCE/NGOS

ACT

CURRENT EMPLOYER
Are you currently in a teaching position?		Yes		No
• If yes, please indicate Grade (s) you are
responsible for
Number of years in a teaching position		Years		Months
NB: All fields are compulsory and must be completed

Signature of student: ________________________

SCHOOL INFORMATION:

(Completed by the School that will be hosting the student for WIL)

The Primary and/or Pre -Primary School must have a Grade R classroom.

Please complete in full.

FULL OFFICIAL NAME OF

SCHOOL

QUINTILE SCHOOL

1

OR

2

OR

3

OR

4 OR 5

EMIS NUMBER

TELEPHONE NUMBER

FAX NUMBER

EMAIL ADDRESS

GRADES (e.g. R – 7)

LANGUAGE MEDIUM

POSTAL ADDRESS

POSTAL CODE

STREET ADDRESS

POSTAL CODE

AREA / RESIDENTIAL AREA

TOWN

PRINCIPAL

TITLE

INITIALS

SURNAME

PREFERRED NAME

TELEPHONE NUMBER

E-MAIL ADDRESS