Office of Undergraduate Medical Education

Registering as a Student in Year 2, 2010/11

of the
Undergraduate Medical Doctor Program, NOSM
________________________________________________________________
Please provide the following:

Part A: Personal Information

NOSM ID#_____________________

Title: (Mr. Ms. Mrs. Dr.)_______

Name: ________________________________________________________________
(Legal Surname/Family Name) (All Legal Given Names)

Former Surname/Family Name: ____________________________________________

Date of Birth:___/___/____ Social Insurance Number________________________

Year/month/day (Required by Canada Revenue Agency only for eligibility to receive scholarships,
awards, bursaries - if not already on file. Otherwise not required.)
Address Information

Home/Permanent/Mailing Address (if different from address while attending NOSM)

Address: ___________________________________________________Apt._______________

City: ______________________________________________________ Prov./State__________

Country: _____________________Postal/Zip Code:_________________

Telephone Number: ( ) _______________ (Land Line) ( ) ____________________ Mobile)

Is this your preferred contact address information while attending NOSM (Sept-June)? □ Yes □ No

Current/Local (school year) Address

Address: _________________________________________________ Apt. ________________

City: ____________________________________________________ Prov. ________________

Country: ____________________Postal Code: ____________________

Telephone Number: ( ) _______________ (Land Line) ( ) ___________________ (Mobile)

Is this your preferred contact address information while attending NOSM (Sept-June)? □ Yes □ No

Emergency Contact Information

In the event of an emergency situation, who should NOSM contact on your behalf?

Name: __________________________________Telephone:_____________________________
Relationship: _____________________________
Student Name: ___________________________

Part B: Program Registration Information

Degree: Medical Doctor MD Program Name: Undergraduate Medical Education Program

Faculty: Faculty of Medicine Status: Full-time Year Level: Two

Assigned Campus Location: Lakehead University (West) ____ Laurentian University (East) ____

Course Information
Course Code Course Number Course Title

MEDS 5205 Northern and Rural Health

MEDS 5225 Personal and Professional Aspects of Medical Practice
MEDS 5245 Social and Population Health
MEDS 5265 Foundations of Medicine
MEDS 5285 Clinical Skills in Health Care
MEDS 5305 Elective
NOTE: All Northern Ontario School of Medicine Undergraduate Medical Doctor Program Year 2
students eligible for the Fall/Winter 2010/2011 academic session will be registered in the slate of
courses noted above. Individualized program timetables will be provided at a later date.

I certify that all information supplied is complete and correct and I understand that I will be subject
to the appropriate sanctions arising from any false information provided on this form. I agree to
supply documents in support of these statements, if requested.

Student signature:________________________________ Date: _______________________

The Northern Ontario School of Medicine, as the Faculty of Medicine for Laurentian University and
Lakehead University, collects personal information for the purpose of administering learner programs
including admissions, registration, academic advising, academic progression, School related student
activities and services, information and library systems, financial accounts, assistance, awards and
scholarships, graduation, university advancement, alumni relations, research and statistical reporting to
government agencies. Information may be shared with Lakehead University and Laurentian University as
required to administer learner programs. We respect your privacy and at all times your information will be
protected in accordance with the Freedom of information and Protection of Privacy Act. Direct any
questions regarding this collection to the NOSM Registrar Sarena Knapik, West Campus, 807-766-7377
sarena.knapik@normed.ca

To ensure your status as an active student in the MD program is maintained, please

complete this form and return to the Office of Learner Affairs, to be received by the
deadline date of July 23, 2010 to: Sarena Knapik, NOSM Registrar
Northern Ontario School of Medicine
Lakehead University –West Campus
955 Oliver Road
Thunder Bay, ON P7B 5E1

Fax: 807-766-7485
Please see the following for information re:
1. Fees and payment of fees
2. Financial Aid
3. Student ID card
4. Your university campus Student Union/Association Health Plan options
5. NOSM Criminal Record Disclosure form and Consent and Authorization form

Northern Ontario School of Medicine Registration Form Year 2, 2010/11 Page 2

Fees and Payment Information

Your NOSM tuition and required ancillary and technology fees are shown in the chart below.
Payment via the Installment Option will have a one-time Installment Fee levied of $55.00.
Please note that the payment deadline date noted on the attached chart is August 16, 2010.
Tuition and ancillary payments made after this date are normally assessed a $65.00 Late
Fee.

Payment of all tuition, ancillary, technology fees, residence/meal plans etc.(if applicable) are to be
made to the host university directly. E.g. If you are attending medical school at the Laurentian
University (East) campus, you will make your payments to Laurentian and if you are attending
medical school at the Lakehead University (West) campus, you will make your payments to
Lakehead.

Payment at the Lakehead University (West) campus:

Student Fees Payment Methods and Account Information can be found at

http://finance.lakeheadu.ca/?display=menu&mid=6 and at the Financial Services Office,
University Centre, Room 0002A (Your Lakehead University issued Student ID# will be required to
remit your fees in person)

Payment at the Laurentian University (East) campus:

Student Fees Payment Methods and Account Information can be found at:
http://www.laurentian.ca/Laurentian/Home/Departments/Student+Fees/PAYMENT+OF+FEES/Py
mt+Methods+P.htm and at Parker Tower, 1st Floor, R.D., P-111 (Your Laurentian University
issued Student ID# will be required to remit your fees)

OSAP/Financial Aid Information

For OSAP/Financial Aid Information, please contact the Northern Ontario School of Medicine,
Office of Learner Affairs, West campus: 807-766-7388 or East campus: 705-662-7264

Northern Ontario School of Medicine Registration Form Year 2, 2010/11 Page 3

 Tuition and Fees

NOTE: Student Registration in the Medical Doctor Program Year 4 is not complete until payment
has been finalized in accordance with the terms outlined below:

WEST Campus (Lakehead University) Tuition and Ancillary Fee Due Dates
Due Date Amount
First Second Third Fourth
Year Year Year Year
Full Payment August 16, 2010 $18,260* $19,260 $19,260 $19,260

First Installment (includes installment fee of $55.00) August 16, 2010 $10,575 $11,575 $11,575 $11,575

Second Installment January 4, 2011 $7,740 $7,740 $7,740 $7,740

Tuition Fees $17,200 $17,200 $17,200 $17,200

Ancillary Fee $960 $960 $960 $960

Technology Fee $1,100 $1,100 $1,100 $1,100

Total $19,260 $19,260 $19,260 $19,260

*First year students pay a deposit of $1,000 on admission which is

credited to their account prior to August 16, 2010.

EAST Campus (Laurentian University) Tuition and Ancillary Fee Due Dates
Due Date Amount
First Second Third Fourth
Year Year Year Year
Full Payment August 16, 2010 $18,016* $19,016 $18,858 $18,858

First Installment (includes installment fee of $55.00) August 16, 2010 $10,331 $11,331 $11,173 $11,173

Second Installment January 4, 2011 $7,740 $7,740 $7,740 $7,740

Tuition Fees $17,200 $17,200 $17,200 $17,200

Ancillary Fee $716 $716 $558 $558

Technology Fee $1,100 $1,100 $1,100 $1,100

Total $19,016 $19,016 $18,858 $18,858

*First year students pay a deposit of $1,000 on admission which is

credited to their account prior to August 16, 2010.
Northern Ontario School of Medicine Registration Form Year 2, 2010/11 Page 4

Refund Schedule

At registration, a total of fees is calculated and charged to your student account. Refunds are
based on total fees charged, not on the amount that has been paid. Compulsory ancillary and
incidental fees are non-refundable once the academic year has begun. In the case of withdrawal,
the amount credited to your student account will be based on the following schedule:

Refund Schedule

Withdrawal Date Percentage Refund

Prior to September 24, 2010 100%

Prior to November 5, 2010 75%

Prior to December 17, 2010 50%

Prior to February 11, 2011 25%

After February 11, 2011 0%

Student Photo ID Card is Renewed

Laurentian University, East Campus students

How can you do this?

All East campus students should go to the J.N. Desmarais Library – Laurentian University, with
your Student ID card that was issued to you in Year One to complete a Renewal form and receive
an updated Sticker for your card. Stickers may also be obtained from the NOSM Health Sciences
Library later in the summer. You will be advised when the stickers are available for pickup.

Lakehead University, West Campus students

ID cards are still valid as is. No action is required.

Replacement Student ID cards

Any lost Student ID card may be replaced by the university library at the campus at which you are
registered. Please contact the respective campus university library, The Chancellor Paterson
Library – Lakehead University or the J.N. Desmarais Library – Laurentian University.
for details regarding process, cost, etc.
Northern Ontario School of Medicine Registration Form Year 2, 2010/11 Page 5

Student Union/Association Health Plan

As a registered undergraduate Medical Doctor Program full-time student at either Lakehead

University or Laurentian University, you have paid for, and are entitled to, all of the services that
any full-time undergraduate student enjoys as a member of the university student
union/association. Part of the fees you have paid include charges that go toward the student
union/association sponsored Health Plan. Upon review of the health plan you may find that you
have comparable coverage already in place. If this is the case and you meet all of the conditions,
you may elect to waive the health plan coverage at the university campus at which you are
registered.

To do this, you must contact the student union/association at the university so that you may
complete an Opt-out Form. This will result in a refund of fees you have paid in support of the
health plan. The deadline date to Opt-out of the Health Plan is late September. Please check
with the campus student union/association for Final Opt-out Date information.

You are advised to contact the Lakehead University Student Union at 807-343-8259, or the
Laurentian University Students’ General Association at 705-675-1151 ext.1064 directly for more
information on the Health Plan and other services they provide.

NOSM Criminal Record Disclosure Form

As part of the registration process of each academic year (Year 2, 3 and 4), continuing
NOSM MD students must complete, sign and return the attached NOSM Criminal Record
Disclosure Form and the corresponding Consent and Authorization Form. Failure
to complete and return the forms may result in the revocation of registration in the NOSM
MD program. Please see attached forms.
Northern Ontario School of Medicine Registration Form Year 2, 2010/11 Page 6

Northern Ontario School of Medicine

Criminal* Record Disclosure Form

Each year as part of their course of study, medical students in the MD program administered by
the Northern Ontario School of Medicine (NOSM) will participate in placements that involve
clinical and personal interaction with members of vulnerable populations. These placements are
administered by organizations that often require a criminal records background check, which was
performed prior to the commencement of study with the NOSM.

The NOSM requires each student to disclose whether they have been convicted or charged with
a criminal offence following completion of the criminal records background check in order for the
student to remain in the MD program and participate in placements. This form must be
completed and signed as part of the registration process of each academic year. Please
return this signed form to the NOSM Registrar, Office of Undergraduate Medical Education, West
Campus, NOSM, no later than October 1st of each year. Failure to complete the form may
result in the revocation of registration in the NOSM MD program.

Please note that if you answer “yes” to question 1 or 2 below, you are strongly advised to consult
with the College of Physicians and Surgeons of Ontario (416-967-2600). Medical school
graduates with criminal records may not be able to receive a license to practice medicine in
Canada.

Please note that providing false or misleading information on this form, or concealing or
withholding material information may result in the revocation of a student’s registration in
the MD Program.

Student Name Student NOSM ID Number Year Level of Study

Since completing the mandated Criminal Records Background Check upon admission to
NOSM;

1. Have you been convicted of a criminal* offense in Canada or elsewhere for which a
pardon has not been granted?

Yes No

If the answer to this question is “Yes”, please provide the following information on the
reverse side of this form for each charge:

a) Name of offense
b) Date and place of conviction
c) Sentence

2. Are there any criminal* charges pending against you?

Yes No

If the answer to this question is “Yes”, please provide the following information on the
reverse side of this form for each offense:

a) Name of offense
 b) Details of charge

*For the purposes of this form, “criminal” refers to an offense or charge under the Criminal Code
of Canada, or under another Federal statute (which includes drug, tax and customs laws), or an
equivalent offence or charge under a foreign statute or law.
Northern Ontario School of Medicine Registration Form Year 2, 2010/11 Page 7

Consent and Authorization

In connection with my continued participation in the MD Program administered by the Northern

Ontario School of Medicine (“NOSM”), I understand and agree that the information provided on
the Criminal Record Disclosure form (“CRD Form”), and inquiries further described herein, will
result in the collection, use and disclosure of personal information about me and will result in
NOSM obtaining my criminal background information.

I hereby declare that to the best of my knowledge, the information I have provided on the CRD
Form is complete and accurate in every respect. I understand that a false statement may result in
the revocation of my registration in the MD Program. I further understand that this Consent and
Authorization will be valid for the duration of my participation in the MD Program.

If required by NOSM in its sole discretion, I hereby consent and agree to apply for and obtain a
criminal records background search(es), at my sole expense, and provide the written results of
such search(es) to NOSM. I consent and authorize NOSM to disclose the information contained
in the CRD Form, and the results of any subsequent criminal record background check(s) to other
institutions and organizations that are involved in my educational development and are
associated with the MD Program, including, without limitation, hospitals, medical clinics, and
educational institutions, including Lakehead University and Laurentian University. I understand
and recognize that collection, use and disclosure of the information provided in the CRD Form
and any subsequent criminal record search(es) is necessary for determining my suitability for
placements and educational opportunities as provided by the MD Program.

I further undertake to inform the Office of Undergraduate Medical Education, NOSM, of any
changes or developments that relate to the information provided on the CRD Form as soon as it
is known to me, including information regarding any criminal charges made against me during the
course of the MD Program, and the details and results of each charge. I acknowledge that failure
to report such information may result in the revocation of my registration in the MD Program.

Student/Learner Signature: ___________________ Date: ___________________

Student/Learner Name: (please print)__________________________

The Northern Ontario School of Medicine, as the Faculty of Medicine for Laurentian University and
Lakehead University, collects personal information for the purpose of administering learner programs
including admissions, registration, academic advising, academic progression, School related student
activities and services, information and library systems, financial accounts, assistance, awards and
scholarships, graduation, university advancement, alumni relations, research and statistical reporting to
government agencies. Information may be shared with Lakehead University and Laurentian University as
required to administer learner programs. We respect your privacy and at all times your information will be
protected in accordance with the Freedom of information and Protection of Privacy Act. Direct any
questions regarding this collection to the NOSM Registrar Sarena Knapik, West Campus, 807-766-7377
sarena.knapik@normed.ca
 -30-

Northern Ontario School of Medicine Registration Form Year 2, 2010/11 Page 8