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CUSTODIAN FOR MINORS STUDYING IN CANADA CUSTODIANSHIP DECLARATION (Collège Boréal)

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File type: PDF

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Citizenship and
Immigration Canada
Citoyenneté et
Immigration Canada
PAGE 1 OF 2
IMM 5646 (01-2015) E
PROTECTED WHEN COMPLETED - B
(AUSSI DISPONIBLE EN FRANÇAIS - IMM 5646 F)
ALSO AVAILABLE ON CIC WEB SITE AT : http://www.cic.gc.ca
CUSTODIANSHIP DECLARATION -
CUSTODIAN FOR MINORS STUDYING IN CANADA
STUDENT INFORMATION
Family name Given name(s) Citizenship
Y D M
Date of birth Sex
FemaleMale
Name and address of school in Canada
Address where student will reside in Canada
PARENTS/GUARDIANS INFORMATION (Preferably from both parents/guardians)
Parent/Guardian 1 Parent/Guardian 2
Full name
Family name Given name(s)Family nameGiven name(s)
Date of birth
Y D M Y D M
Home address
Telephone number
CUSTODIAN INFORMATION
Family name Given name(s)
Status in Canada
Permanent resident
Canadian citizen or
Y D M
Date of birth
Home address
Telephone no.
The application of the official seal below confirms that the notary public has received evidence that the custodian is a Canadian citizen or a permanent resident, is over 19 years of
age, and currently resides at the home address stated above.
I, (name of custodian), hereby solemnly declare that I will undertake the full custodianship for the
said student, (name of student), during his/her stay in Canada, while under the age of majority in
the province in which he/she resides. As a custodian, I have made the necessary arrangements for the care and support of the said student in place of the parents as appropriate.
By signing this custodian agreement, I certify that I reside within a reasonable distance of the student's intended residence and school and will be able to fulfil my obligations as a
custodian in the event of an emergency.
Sworn before me at: (city), in the province of (province/territory), country (if applicable).
This day of (month), (year).
OFFICIAL SEAL OF NOTARY PUBLIC
Signature of custodian
Year Day Month
Date
Signature of notary
Toronto District School Board
5050 Yonge Street
Toronto, Ontario
M2N 5N8
PAGE 2 OF 2
IMM 5646 (01-2015) E
Citizenship and
Immigration Canada
Citoyenneté et
Immigration Canada
PROTECTED WHEN COMPLETED - B
(AUSSI DISPONIBLE EN FRANÇAIS - IMM 5646 F)
ALSO AVAILABLE ON CIC WEB SITE AT : http://www.cic.gc.ca
CUSTODIANSHIP DECLARATION -
PARENTS/GUARDIANS FOR MINORS STUDYING IN CANADA
STUDENT INFORMATION
Family name
Given name(s)
Citizenship
Y D M
Date of birth Sex
FemaleMale
Name and address of school in Canada
Address where student will reside in Canada
PARENTS/GUARDIANS INFORMATION (Preferably from both parents/guardians)
Parent/Guardian 1 Parent/Guardian 2
Family name Given name(s) Family name Given name(s)
Full name
Date of birth
Y D M Y D M
Home address
Telephone number
CUSTODIAN INFORMATION
Family name Given name(s)
Status in Canada
Canadian citizen or
Permanent resident
Y D M
Date of birth
Current residential address
Telephone no.
I/We, and (names of parents/guardians),
the parents/guardians of the said student, (name of student), hereby grant full custodianship to
(name of custodian), during the student's stay in Canada, while he/she is under the age of majority in the
province in which he/she resides. I have made the necessary arrangements for the care and support of the said student such that the custodian should act in the place of me/us,
the parents. By signing this custodian agreement, I/We affirm that I am/we are satisfied the above appointed custodian resides within a reasonable distance of my/our child's
intended residence and school and will be able to fulfil his/her obligations as a custodian in the event of an emergency.
Sworn before me at: (city), in the province of (province/territory), country (if applicable).
This day of (month), (year).
My/Our child will reside:
with the appointed custodian, in the school dormitory, or
with another person:
(please provide name and indicate relationship).
Signature of parent/guardian (1)
Year Day Month
Date Signature of parent/guardian (2)
Year Day Month
Date
OFFICIAL SEAL OF NOTARY PUBLIC
Signature of notary
Toronto District School Board
5050 Yonge Street
Toronto, Ontario
M2N 5N8
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CUSTODIAN FOR MINORS STUDYING IN CANADA CUSTODIANSHIP DECLARATION (Collge Boral)

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Completed 19 January 2021

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