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									                                                     Image Consultant Certificate Program
                                                                 Application for Admission to Program

                                          Please print neatly and clearly

Name: (First, Last) ________________________________________________________________________
Address: ________________________________________________________________________________

Phone: (Home) ____________________________ Email: ________________________________________

Date of Birth: ________________________               Occupation: ___________________________________

Please Enclose the Following:
   1. A cheque for the non-refundable, non-transferable application fee of $50 made out to “Langara College
       Continuing Studies”

   2. Entry into the program will be based upon completion of Grade 12 or equivalent and fluency in

   3. A Resume, outlining the following:
           •   Educational background
           •   Work experience

   4. Personal Essay: Double-spaced, typed, 1 page: What has made you apply to the program at this time?
   5. Completed and signed Image Consultant Program Consent form

I certify that all statements on this application and within the attachments are accurate and true.
Signature: _______________________________________ Date: __________________________

                                   Application deadline: January 10, 2011
                       Please mail the complete application form and documents to:
Attention: Cora Van Wyck
Langara College Continuing Studies
100 West 49th Avenue                                  Phone: 604-323-5971
Vancouver, BC                                         Fax: 604-323-5899
V5Y 2Z6                                               Email:

                                 Consent and Waiver Form
             For Student Participating in Image Consultant Certificate Program
                            Students are 19 years of age or over.

Students will be participating in the Image Consultant Certificate Program where they will
learn to assess individual body types and complexions. Students in the class will be learning
examples for each other.

Students will be participating in lectures, discussions and practice activities where they will
assess and critique each others’ body type and complexion related to clothing that is worn by
students. These critiques will be conducted in a professional and respectful manner and are
not to be taken personally. Discrimination will not be tolerated and is a violation of the
Langara Code of Conduct.

Students will only be supervised by Langara staff during class times.

I hereby give my consent, and acknowledge by my initial and signature that:

I have no illnesses, allergies or disabilities that may require special attention, except as
described here:

I am aware of the usual risks and dangers inherent in participation in all of the activities
associated with this Fashion and Image Certificate program, which may include required
participation in field trips off of Langara campus.

I understand that I will provide and will also be receiving a critique of my body type and
complexion and that this critique will be performed in a professional manner.

I will supply suitable clothing for my participation in all activities associated with the
Fashion and Image Certificate Program, as instructed by the College faculty course
instructors and identified clothing lists provided to me.

I am aware that I should contact the College course instructor for further information if I
am unaware what clothing is required for the activities or possible conditions of this
Program. I understand that it is my responsibility to ensure I have all necessary clothing.

I am aware that the College’s Code of Conduct and Student Policies apply during my
participation in this Program. I will be responsible for any costs caused by my failure to
abide by the Code of Conduct or Policies, including any costs to return home.

I am aware that I am responsible for my own self-care and seek appropriate heath care
support for existing health conditions.

I understand that alcohol, recreational or illegal drugs are not permitted at classes and their
use is not permitted before or at any clinical setting. If this rule is disregarded the
disciplinary process will be initiated.

I understand that I cannot present myself as an Image Consultant Certificate holder until I
have formally received my Certificate from Langara College.

I am 19 years of age or more and have read and understand the terms of this Consent and
Waiver, and understand that it is binding upon me, my heirs, executors and administrators.

                             Student:                                        Witness:
            Signature                                      Signature

            Name                                           Name

            Address                                        Address

            Date                                           Date

Please Note: Langara College student policies are on the Langara College web site.
Approved: 2010/10/20

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