Fillable 2020-2021 075 FORM 1 Summer School 2021 Secondary ELearning Courses

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2020-2021 075 FORM 1 Summer School 2021 Secondary ELearning Courses

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The 2020-2021 075 FORM 1 Summer School 2021 Secondary ELearning Courses form is 4 pages long and contains:

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  • 18 check-boxes
  • 99 other fields

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BASIC INFORMATION
Legal Last Name
First Name
Middle Name
Preferred Name (if different from legal name, please indicate below):
Birth Date: (MM/DD/YYYY)
Preferred Last Name
Preferred First Name
Gender Identity Male: □ Female: □ Prefer Not To Disclose □ Prefer To Identify As________________
Email Address:
ADDRESS
# and STREET NAME: Apt. # / Unit #
CITY:
PROVINCE:
POSTAL CODE:
EMERGENCY CONTACT
Relationship to Student: Parent/Guardian: Yes No
Name (Last Name, First Name):
Home Phone: Cell Phone:
Parent/Guardian: (if under 18 years of age)
Lives with Parent: Yes No
Custody: Exclusive: Both Parents: Joint: Crown
Parent/Guardian
Name (Last Name, First Name):
Home Phone: Cell Phone:
Parent/Guardian Email:
NOTE: OFFICIAL DOCUMENTATION WILL BE REQUIRED TO VERIFY INFORMATION PROVIDED.
www.thelearningcentres.com
2020-2021: 075
FORM 1a
MEDICAL INFORMATION
Life-threatening Medical Conditions
Does the student have a life-threatening medical condition? □ Yes □ No
Please provide details:
Does the student
require an EPIPEN?
□ Yes □ No
Does the student require Insulin, Glucagon, other? Please specify:
Non-life-threatening Medical Conditions
Are there any non-life-threatening medical conditions the school should be aware of?
□
Yes
□
No
Please provide details:
COUNTRY OF BIRTH, CITIZENSHIP AND LANGUAGE
Country of Birth:
Province of Birth:
Country of Citizenship:
If not born in Canada, original date of first entry into Canada:
Month (mm)
Day (dd)
Year (yyyy)
Immigration Document:
Residence Status in
Canada:
□ Canadian Citizen
□ Permanent Resident
□ Work or Study Permit
□ Refugee Status
□ Exchange
Other:
First Language: Language Spoken at Home:
Are you a tax paying citizen of Ontario: Yes □ No □
VOLUNTARY: SELF-IDENTIFICATION OF FIRST NATION, MÉTIS AND INUIT STUDENTS
If choosing to self-identify, please check the
appropriate box:
First Nation
Métis
Inuit
Simcoe County District School Board is committed to providing programs that result in improved success for First Nation, Métis and Inuit
Students. All First Nation, Métis and Inuit Students have the right to voluntarily self-identify in accordance with SCDSB Policy 4195,
Voluntary, Confidential Self-Identification of First Nation, Métis and Inuit Students.
FUNDING INFORMATION
ARE YOU A RECIPIENT OF FUNDING FROM ANY OF THE FOLLOWING AGENCIES?
OW CAS EI WSIB ODSP FNMI
Worker’s Name: Phone:_________________________
I give permission to the Learning Centre to correspond with my case worker regarding information about my attendance and progress.
DATE: ________________________________________STUDENT SIGNATURE:______________________________________________
www.thelearningcentres.com
2020-2021: 075
FORM 1b
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signature
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www.thelearningcentres.com
EDUCATIONAL BACKGROUND
Do you currently attend a secondary school? Yes
No
Are you a graduate? Yes No
If yes, name of secondary school:
If no, name of last full-time secondary school attended:
Location of last secondary school attended:
Year of attendance for last secondary school attended:
SPECIAL EDUCATION ASSISTANCE
Student previously received special education assistance:
Yes
No
Unsure
Student has been identified through the Identification Placement and Review
Committee (IPRC) process:
Yes
No
Student has an Individual Education Plan (IEP):
Yes
No
Student has a Safety Plan or Notification of Worker Risk:
Yes
No
ACKNOWLEDGEMENT
Personal information collected on this form will be used to establish the Ontario Student Record (OSR), support the provision of educational
services and to administer health and first aid services and/or medical emergency response to students as required. Information is collected
under the authority of the s.170, s.190, s.264, and/or s.265 of the Education Act and Sabrina’s Law in accordance with the Municipal
Freedom of information and Protection of Privacy Act. Please refer to the Student Information Practices statement available on the Simcoe
County District School Board website for further information at www.scdsb.on.ca
. Questions regarding information collected on this form
should be directed to the school principal.
MEDIA RELEASE
We need your permission to share good news stories about our school that may include you. From time to time, school and
class activities, such as projects, achievements, pl
ays, sports and presentations are covered by local media, and may be
shared by board and school staff on social media. We are seeking your permission for the following:
- To post identifiable photographs and/or recordings of you, the student, on school and board websites, newsletters and social
media sites (including Twitter, Facebook, Instagram, YouTube and our blog www.sharingsimcoe.com
).
- To allow the media to photograph, interview or record (video and audio) you, the student, as part of a good news story about
the school or board. The story may include identifiable images.
I give permission for my photograph and/or recordings to be used as outlined above.
Parent/Guardian
or Adult Student:
Please Print Signature Date
2020-2021: 075
FORM 1c
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signature
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FOR OFFICE USE ONLY www.thelearningcentres.com
Summer School 2021 Course Selections
Student Legal Name:
Last Name First Name Middle Name
OEN: Mature Student Flag: Yes
No
eLearning Course – July Term (July 5 to July 30, 2021*) PRISM:
Course: ___________________
Change to: _________________
Date: _______________________ Initials _____________
*CHV2O (Civics) and MPM1H (Math Transfer) run July 5 – July 16
*GLC2O (Careers) runs July 19 – July 30
eLearning Course – August Term (July 29 to Aug 26, 2021) PRISM:
Course: ___________________
Change to: ________________ Date: _______________________ Initials _____________
*CHV2O (Civics) runs July 29 – Aug 12
*GLC2O (Careers) runs Aug 13 – Aug 26
Identification: Document Type:
Grad: Yes No Order OSR: Yes No
Course Approved by:
_____________________________________________
Principal/Vice Principal/Coordinator
________________________________________________________
School Name and Location
2020-2021: 075
FORM 1d
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2020-2021 075 FORM 1 Summer School 2021 Secondary ELearning Courses

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Completed 10 May 2021

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