Fillable ELEMENTARY STUDENT REGISTRATION FORM (Grand Erie District School Board)

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ELEMENTARY STUDENT REGISTRATION FORM (Grand Erie District School Board)

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Country of origin: CANADA
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Filed in OSR Retention: E + 10 years (E – retired student) Rev: November 2020
ELEMENTARY STUDENT REGISTRATION FORM
349 Erie Avenue, Brantford, N3T 5V3
519-756-6301 1-888-548-8878
www.granderie.ca
Notice to Parent/Guardian
Thank you for your interest in an elementary education with the Grand Erie District School Board. To register a student, the
parent/guardian is required to provide information to the school by completing this Registration Form. Ensure that you complete all
sections and provide the school with all of the original documentation required, as noted on the form.
Notice of Collection and Use of Personal Information
Information on this Registration Form is collected under the legal authority of the Education Act and in accordance with the Municipal
Freedom of Information and Protection of Privacy Act [MFIPPA]. It will be used to establish the Ontario Student Record [OSR], and for
student and education related purposes, such as registration, administration, communication, data reporting, and Student
Transportation Services Brant Haldimand Norfolk. Student information such as name, D.O.B. and contact information is released to
the Regional Health Units in accordance with the Health Protection and Promotions Act and the Immunization of School Pupils Act.
Questions or concerns should be directed to the principal of this school or email info@granderie.ca
SCHOOL START DATE:
STUDENT INFORMATION SUMMARY
OFFICE: DOB Verification Document:
LEGAL FIRST NAME
LEGAL MIDDLE NAME(S)
BIRTH DATE - MM/DD/YYYY
GENDER
Male Female
Prefer not to Disclose
Prefer to Specify
LIVES WITH:
Both Parents Mother Father
Legal Guardian
Other (specify):
Is there a court order limiting access of
one or both parents?
Yes No
(if yes, provide documentation)
ADDRESS
HOME PHONE NUMBER
Apt/Unit House # Full Street Name City/Town Postal Code
Please help us to understand special living arrangements (e.g., student does not live with a parent) and/or custody orders by providing details here:
LEGAL PARENTS and GUARDIANS
NAME of LEGAL PARENT/GUARDIAN #1
PHONES (indicate Home, Work or Cell)
H
W
C
MAIN:
ADDRESS (if different from student)
2
ND
:
Apt/Unit House # Full Street Name
3
RD
:
E-MAIL ADDRESS (only if you consent to receive emails from the school):
City/Town Postal Code
NOTES-- PARENT/GUARDIAN #1 If you wish to provide information that will help us to understand the student’s family context such as stepparent, common-law spouse
NAME of LEGAL PARENT/GUARDIAN #2
PHONES (indicate Home, Work or Cell)
H
W
C
MAIN:
ADDRESS (if different from student)
2
ND
:
Apt/Unit House # Full Street Name
3
RD
:
E-MAIL ADDRESS (only if you consent to receive emails from the school):
City/Town Postal Code
NOTES-- PARENT/GUARDIAN #2 If you wish to provide information that will help us to understand the student’s family context such as stepparent, common-law spouse
NAMES OF SIBLINGS ATTENDING SCHOOLS IN GRAND ERIE who live at the same address as the student
Filed in OSR Retention: E + 10 years (E – retired student) Rev: November 2020
SCHOOL HISTORY
DETAILS OF PREVIOUS SCHOOLING
OEN (Ontario Education Number) if known
Public Catholic Private Home Schooled Out of Province/Country
LAST SCHOOL ATTENDED
LOCATION
LANGUAGE OF LAST SCHOOL ATTENDED
DATE OF ENTRY TO FIRST ELEMENTARY SCHOOL -MM/DD/YYYY
English French English and French Other (Specify):
Has student attended a Grand Erie school before? Yes No Not Sure
Is student currently expelled from previous school? Yes No
Was Special Education Programming accessed at the previous school? Yes No Not Sure
Grade student is entering:
If yes, was there an Individual Education Plan (IEP)? Yes No Not Sure
CITIZENSHIP/STATUS original Citizenship and Immigration documents must be produced if student is new to the Grand Erie District School Board
Canadian Citizen
Permanent Resident
Refugee Status
Study Permit/Visitor Record
Diploma Status/Minister’s Permit
Exchange Student
Parent’s Study Permit
Parent’s Work Permit
Other Status
Not Applicable
COUNTRY OF CITIZENSHIP
DATE OF ENTRY TO CANADA (if applicable) – YYYY/MM/DD
COUNTRY/PROVINCE OF BIRTH
PREVIOUS PROVINCE/COUNTRY OF RESIDENCE
FIRST LANGUAGE SPOKEN:
LANGUAGE CURRENTLY SPOKEN AT HOME:
English French Other (Specify)
EMERGENCY CONTACT/MEDICAL INFORMATION (OFFICE: ANA Reaction Med Form Med. Admin. Form )
Does student have a condition that could lead to anaphylactic shock? Yes No
if yes, please provide medical information/documentation
Please provide medical information/documentation that the school needs to be aware of:
EMERGENCY CONTACT (other than parent/guardian)
Can pick up student
RELATIONSHIP
PHONE(S)
Yes No
EMERGENCY CONTACT (other than parent/guardian)
Can pick up student
RELATIONSHIP
PHONE(S)
Yes No
EMERGENCY CONTACT (other than parent/guardian)
Can pick up student
RELATIONSHIP
PHONE(S)
Yes No
I have obtained the consent of the person(s) listed above to have their name and telephone number used for emergency purposes
Yes
TRANSPORATION INFORAMTION (OFFICE: Bus Request Form JK Contract Form Transportation Life-Threatening Management Form )
STUDENT WALKS IS DRIVEN TAKES THE BUS
ADDITIONAL INFORMATION (if applicable)
SELF-IDENTIFICATION (if applicable) this is voluntary/optional
STUDENT LIVES ON:
First Nations Métis Inuit
Six Nations of the Grand River Mississaugas of the Credit
LUNCH BREAKS It is important that we know where your children are. Students who eat at school must provide a signed, dated note with your consent to leave
school property during breaks.
Please indicate whether your child: WILL be eating at school WILL NOT be eating at school
PERMISSION ACKNOWLEDGEMENTS AND RELEASE OF INFORMATION
Media Consent: I give permission for my child’s personal information (e.g., picture, video, name, school work) to appear
on school websites, on the board’s social media outlets such as its YouTube channel, Facebook, Twitter account and in
school-related stories in the newspaper, school or board brochures, student produced online newspapers and reports on
websites. I understand that by consenting, my child’s photo, video, school work, and/or name could be used in a way that
makes it accessible to the public. Yes No
Consent to Receive School Emails: Canada has implemented Anti-Spam legislation which requires us to have your
consent to send you emails with content related to “commercial activity” such as information on yearbook sales, school
fundraisers, field trips, student pictures, books, dance tickets, etc. If you wish to receive these emails, please indicate that
here. You may withdraw your consent at any time by contacting the school. Yes No
I verify that the information provided on this form is true and correct. I understand that it is my responsibility to inform
the school immediately of any changes to the information contained on this form.
SIGNATURE OF PARENT/GUARDIAN
DATE
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ELEMENTARY STUDENT REGISTRATION FORM (Grand Erie District School Board)

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Completed 27 June 2021

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