Indigenous Student Information Form

The Office of Indigenous Initiatives staff are here to support you while you are a student at Nipissing University. We can assist you with your academic and personal needs. At times, we may refer you to other departments and services within Nipissing University such as Accessibility Services, Career Counselling, Personal Counselling, Academic Advising, etc. To make such referrals, we may need to discuss the matter with a staff person in our office – and sometimes with a staff person from another department – to ensure that your matter is dealt with efficiently. You may also wish to have us share information with another department. By signing this consent form, you agree that the Office of Indigenous Initiatives staff may discuss and refer your academic or personal matter with other appropriate Nipissing University staff or faculty. Grade reports and other information for sponsorship purposes are sometimes requested by Indigenous education administrators or other sponsoring agencies/organizations as a requirement to receive post-secondary financial assistance. Please sign this release form to authorize Indigenous Initiatives staff to provide such information. Please note that only information directly related to the matter at hand will be disclosed to the education administrator or sponsoring agency. I have read the above statement, and I agree that Indigenous Initiatives staff may release information about me to other Nipissing University staff and/or faculty as needed in order to provide me academic and/or personal assistance.

The information on this form is collected under the authority of the Nipissing University Act, 1992. It is related directly to and needed by the University to support you in Indigenous Initiatives at Nipissing University. The information will be used by employees of the Office of Indigenous Initiatives, the Office of Student Development and Services, and other departments on a need to know basis. If you have any questions about the collection, use and disclosure of this information, please contact the Office of Indigenous Initiatives, Nipissing University, 100 College Drive, North Bay, ON P1B 8L7, (705) 474-3450, ext. 4509.