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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
