Health Science

2022

University of Otago Foundation Studies

Certificate enrolment form

The purpose of this form is to obtain information required by the University of Otago, Ministry of Education, Tertiary Education
Commission and other government agencies for statistical and administrative reasons.

Email the completed form to pathways.admissions@otago.ac.nz

If you require any assistance, please telephone University of Otago on 64 3 479 5250.

1. Previous enrolment at Otago 7. IRD Number

If you have previously studied at the University of Otago, please state your Note: The completion of this section is not compulsory. If you are applying for
first and last year of attendance. a Student Loan, please write your IRD number below. This number will help
Inland Revenue to determine if you are eligible for an interest write-off.
to

Foundation Studies ID number

8. NSN (National Student Number)

University of Otago ID number (if known) If you have an NSN or NZQA number, please write it here.

2. Name 9. Citizenship/Residency Status

Original or witnessed evidence of your name must be attached if not already Please select the box that describes your present citizenship or residency status.
supplied.
1. New Zealand Citizen*
Title (select one) Mr Miss Ms Mrs Mx 2. New Zealand Residence Class Visa Holder*#
Other (please specify) 3. International Student

Legal family name 4. Tokelau, Niue or Cook Islands Citizen

5. Australian Citizen*
6. Australian Permanent Resident*
* original or witnessed evidence of New Zealand or Australian citizenship or residency
Legal given name(s)
status must be attached if not already supplied.
# You are a New Zealand residence class visa holder if you hold either a New Zealand
resident visa or a New Zealand permanent resident visa.
3. Preferred given name If you are an international student, or a permanent resident of New Zealand or
Australia, please specify your country of citizenship below.

4. Previous name(s)
Original or witnessed evidence of name changes must be attached if not
* * * IMPORTANT * * *
already supplied.
All students must provide evidence of their birth name, any subsequent change
of name, and date of birth. Acceptable evidence for verification of a student’s
legal name(s) and date of birth is an original or certified copy of the following
document(s):
• birth certificate • dissolution of marriage certificate*
• passport • deed poll*
• certificate of citizenship • statutory declaration issued by Registrar
5. Date of birth
• marriage certificate* of Births, Deaths and Marriages*
Original or witnessed evidence of your date of birth must be attached if not
* These are acceptable evidence for legal name changes only.
already supplied.
Copies of drivers’ licences will not be accepted.
Students should normally have their documents certified as true copies of the
Day Month Year original by one of the following:
• Justice of the Peace
6. Gender • Barrister or Solicitor of the High Court
Male Female
The following may also certify documents:
Gender diverse - please select below • Court Registrar or Deputy Registrar
• Notary Public
Female / Wahine Male / Tāne • University of Otago Administrative or Liaison Staff
• Member of Parliament
Transgender man / Tangata ira tāne
Other officials or professionals should not normally be asked to certify
Transgender woman / Whakawahine documents. Students from remote areas who do not have access to anyone in
SE007

the approved categories should contact Foundation Studies for advice.

Non-binary gender Intersex
10. Ethnic Origin(s) 12. Disabilities
Please indicate the group(s) with which you identify. (Select one or more boxes) Note: The completion of this section is not compulsory. This information
is not carried over from year to year and needs to be supplied again by
111. New Zealand European/Pākehā
returning students.
121. British/Irish
Do you have an impairment, disability or long-term medical condition?
122. Dutch
Yes (please specify below) No (go to section 13)
123. Greek
How would you describe your impairment, disability or long-term medical
124. Polish condition? (Select one or more box)

125. South Slav 1. Deaf 7. Head injury

2. Hearing 8. Mental health
126. Italian
3. Blind 9. Mobility
127. German
4. Vision 10. Speech
128. Australian 5. Specific learning 11. Temporary impairment
129. Other European 6. Medical 12. Other (please specify)

211. New Zealand Māori – Tribal Affiliation (Iwi)

Please refer to the list of Iwi codes and enter the appropriate four-digit
code(s) below. If you identify with more than one Iwi, please list in order Does your impairment, disability or long-term Yes No
of priority. medical condition affect your study?

1st 3rd
2nd 4th 13. Your email address

311. Samoan

321. Cook Island Māori

14. Your mobile telephone number
331. Tongan
(New Zealand numbers only)
341. Niuean

351. Tokelauan

361. Fijian
15. Accommodation
371. Other Pacific Peoples In 2021 while studying I will be:

411. Filipino 1. Sharing a flat or house (flatting)

412. Cambodian 2. Living in a residential college

3. Living with my parents or guardian
413. Vietnamese
4. Living in my own home (including renting)
414. Other Southeast Asian
5. Boarding / homestay
421. Chinese 6. Living elsewhere
431. Indian

441. Sri Lankan

16. Study address
442. Japanese Please give the address you will be living at while you are studying.

443. Korean

444. Other Asian

511. Middle Eastern

521. Latin American

531. African Postcode:

611. Other Telephone ( )

If you identify with more than one ethnic group, please list in order of
your preference (e.g. 211, 111).
17. Permanent home address
Please give an address which can be used to contact you outside terms or
other teaching periods.

11. English language

Is English your first or native language?

Yes No

Postcode:

Telephone ( )
18. Emergency contact person (next of kin) 20. Prior activity
Please provide the details of a person whom we may contact in the event of Were you or will you be resident in New Zealand at 1 October 2021?
an emergency.
Yes (please complete this section) No (go to section 21)
Title (select one) Mr Miss Ms Mrs Dr
Please indicate your main activity or occupation at 1 October 2021
Other (please specify) (Select one circle only)

1. Secondary school student

Family Name
2. Non-employed or beneficiary (excluding retired)
Given Name(s)
3. Wage or salary earner

4. Self-employed
Address
5. University student

6. Polytechnic student

7. House person or retired

Postcode: 8. Private training establishment student

Telephone 9. Wānanga student

21. Previous tertiary study

Relationship Were you enrolled at the University of Otago in 2021?

Yes (Foundation Studies Certificate or Language Centre)

19. Secondary school details Yes (other course) please specify

Please name the secondary school or high school where you are at present,
or were last enrolled.
No
If this school is not in New Zealand please also state the country.
Have you previously attended any tertiary institution, either in New Zealand
School
or overseas, since leaving school? This could include a university, polytechnic,
college of education (teachers’ college), wānanga or private training
Country
establishment. Do not include enrolments in community or hobby courses.
Last Year Enrolled No

What is the highest level of achievement you hold from a secondary school or Yes
high school? Your highest achievement may be an award such as NCEA Level
First year of enrolment at any tertiary institution
1, 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
Last year you were enrolled
Learning shows how many credits you have. (Select one circle only)

NCEA Level 3 Did you study part-time or full-time?

NCEA Level 2 Part-time Full-time

NCEA Level 1 Did you complete your tertiary studies?

14 or more NCEA credits at any level
Yes No
No secondary school qualification
Have you ever been suspended or excluded from any other New
Overseas award (includes International Baccalaureate and Cambridge Zealand tertiary institution”?
International Examinations) (please specify)
No

Yes
Other (please specify)
Name of the institution

In what year did you gain your highest school qualification?

Year

22. First in family

How many of your mātua/caregiver/parent/foster parent(s) that you have Will you be the first person in your close whānau/family (parents,
lived with before coming to university have a bachelor’s degree (BA, BCom, grandparents, caregivers, brother/sister, uncle/aunt/cousin) to attend
BSc, etc.) or higher qualification? university?

None Yes No

Not sure Have you discussed or intend to discuss how university works with the
Yes, 1 does whānau/family member that went to university?

Yes No
Yes, two do

Yes, three or more do

23. Papers for Foundation Studies Certificate
Please add the paper codes for the stream you have been given an offer for.
Paper code Paper name
FOUN001 F2
FOUN004 F2
FOUN007 F2
FOUN040 F2
FOUN046 F2
FOUN002 F3
FOUN005 F3
FOUN008 F3
FOUN014 F3
FOUN041 F3
24. Declaration to be signed by student
I confirm my wish to enrol for the course specified on this form.
I confirm that I have read, understand and accept the declarations below.
I confirm that I will inform the University of Otago if the details provided in this application form change.
The references to eVision below will apply once this service is available to you.
Signature Date
Admission and Enrolment
I declare that all the information now submitted, or which I will later submit,
in connection with my enrolment (whether on a physical form, entered
electronically, or in any supporting documents) is, or when provided will be,
correct and complete.
I authorise the University of Otago to obtain official records and related
information relevant to my application for enrolment from any educational
institution that I have previously attended and from any applicable authority
including the New Zealand Qualifications Authority, International Baccalaureate,
and University of Cambridge International Examinations.
I understand that the University reserves the right to vary or reverse any
decision regarding admission or enrolment made on the basis of incorrect or
incomplete information provided by me.
I confirm that I will have attained the age of 16 by the first day of formal classes
for my proposed course of study.
I understand that I am unable to enrol or remain enrolled for Final Examination
Only if I am suspended under the University’s Academic Progress Policy.
Regulations
I acknowledge that as an enrolled student at the University of Otago I will be
bound by the Statutes, Regulations and other requirements established by, or
under the authority of the University Council.
I acknowledge that my attention has been particularly drawn to:
The Code of Student Conduct which forms part of the University’s Discipline
Statute (published in the University Calendar and on the University’s website); and
The Information and Communications Technology Regulations (published in the
University Calendar and on the University’s website).
Fees and Course Materials
I accept responsibility for the payment of all fees (including tuition fees)
charged by the University. Should I default on payment of all or part of those
fees, I agree to pay all costs relating to the collection of the outstanding debt.
I undertake to return course materials supplied to me in connection with
any paper from which I subsequently withdraw, if that is a departmental
requirement, or to accept liability for payment for the material.
StudyLink
If my fees are paid by a Government Student Loan through the Ministry of
Social Development StudyLink service and I become eligible for a refund of all
or part of those fees, I authorise the University to pay the refund directly back
to StudyLink to be credited against my student loan balance.
Course of Study
I accept responsibility for satisfying myself as to the suitability of my own course
of study. I understand that my course must comply with Programme Regulations
and that I must not undertake a course involving unresolved timetable clashes. I
acknowledge that in finalising my course and in making any subsequent changes
I must abide by requirements of authorised Course Approvers. I acknowledge
Academic English I
Biology
Chemistry - Structure and Bonding
Physics - Mechanics and Energy
Mathematics for Science
Academic English II
Human Biology
Chemistry - Reactivity
Health and Disease
Physics - Thermodynamics and Modern Physics
Day Month Year
that my entitlement to receive any degree or other award is subject to ongoing
checks that I have met all applicable requirements of the relevant programme.
Amendments to Course
If the course for which I have sought enrolment requires amendment (because
of my failure in any examinations or assessment, or because of the regulations
for the programme concerned) I agree that the University may make any
necessary changes to my course. I understand that I will be informed in
writing of any such changes or will have the opportunity to revise my course in
consultation with relevant authorised Course Approvers.
Privacy
I understand that the University of Otago will collect, store, use and disclose
personal information about me in the course of conducting its proper business
and that a unique identifier will be assigned to me to facilitate this. I have
read and understand how such information will be managed and disclosed in
accordance with the Privacy Act 2020, and as outlined on the University website
(http://privacy.otago.ac.nz). I acknowledge that I have the right to access and
seek correction of personal information about me and understand that if I
withhold information or provide false or misleading information my enrolment
may be terminated.
I consent to disclosure of my personal information for purposes related to my
education and wellbeing. Such disclosure may be to my parents, legal guardian
and/or scholarship provider, and may include my course results and personal
information related to my wellbeing. I consent to confidential disclosure of
medical information to my Host family for safety reasons.
Computer Use
I understand that the University may monitor data entered or changed by
users and reserves the right to take disciplinary action in cases involving false,
misleading, or offensive data, and that the University accepts no liability for
consequences arising from the divulging of usernames or passwords to others.
Communications from the University
Important information is sent out during the year to enrolled students. I
understand that, in order to receive this, I must:
a. keep my address details on eVision current, including the physical address
I will be residing at while undertaking study at the University and any email
redirections I have put in place on my student email; and
b. check my student email and eVision portal at least once per week.
I agree to the University communicating on matters related to my enrolment, or
relevant to membership of the University, via the contacts which I have provided
or which I may, in the future, provide. I acknowledge such communications may
include newsletters and similar material of general interest to members and
friends of the University.
Copyright
I understand that I must observe the Copyright Act 1994 in relation to any
teaching materials supplied to me in the course of study at the University and that
I may not make unauthorised sound recordings of lectures or audio conferences
 CHECKLIST FOR STUDENTS
Email the completed form to pathways.admissions@otago.ac.nz

Have you:

attached an original or witnessed copy of your birth certificate, or a witnessed copy of the personal details page(s) of your passport?

attached original or witnessed evidence of any name changes, if not already supplied?

attached original or witnessed evidence of New Zealand or Australian citizenship or permanent residency status, if applicable?

checked that you have completed all relevant sections of this form?

checked that you have added the correct paper codes for your stream?

OFFICE USE ONLY

Approval of course by adviser

I have checked that the course meets programme requirements.

Signature Name of Adviser

Date Day Month Year

Sponsored Checked by

Evidence of name Date

Evidence of date of birth Evidence

of ctizenship/residency Other