PLEASE PRINT CLEARLY & COMPLETE BOTH SIDES. ALL INFORMATION IS REQUIRED.
STUDENT INFORMATION
PROPERTY ADDRESS
CITIZENSHIP
ABORIGINAL ANCESTRY
YES NO If yes: Inuit Metis First Nations
If First Nations: Non-Status Status- Off Reserve Status- On Reserve
If known, what is your Band of Origin? ___________________________________________________________________________
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SCHOOL DISTRICT #40 (NEW WESTMINSTER)
SUMMER LEARNING
OUT-OF-DISTRICT YOUTH REGISTRATION FORM
Students born after July 1, 2000 are considered youth
Date: _________________ OFFICE USE ONLY Enrollment Date: _________________
Grade: ______ YOG: ________ Pupil#: _________________________ PEN#: ________________________________
International: Funded Non Funded Paid _________________________
Registration Documentation (Student): Proof of Citizenship Photo ID
Registration Documentation (Parent/Guardian): Proof of Citizenship Proof of Residency x 2 Photo ID
Counsellor/Administrator Email or Letter on School Letterhead School Name: ______________________________
Parental/Guardian Signature
Additional Documentation: Previous Report Card Official Transcript of Grades
Staff Initial
Legal Last Name: PREFERRED Last Name:
Legal First name: PREFERRED First Name:
Legal Middle Name: Date of Birth (Month/Day/Year):_____________________________
Home Phone Number: Student Cell Phone:
Student Email: (Please print CLEARLY):_________________________________________________________________________
Address: City:
Province: _ Postal Code:
Mailing Address- Same as Property Address? Yes No: ___________________________________________________
Country of Birth: __________________________________City:________________________Province:
Status: Canadian Permanent Resident Refugee Student Visa Work Permit
If Applicable: Student Visa Expiry Date: Work Permit Expiry Date:
Home Language: Language Most Used:
School Year
2019/2020
SUMMER
CURRENT SCHOOL/DISTRICT
School Name: ____________________________________________________ School District: _____________________________
School Counsellor or Administrator Name:* ____________________________ School letter or email attached? YES NO
* It is important to speak with your counsellor to ensure that you are choosing the correct course(s) for your learning plan. Your
school is responsible for submitting your Summer Learning mark to The Ministry of Education for your transcript.
Requested Courses (be sure to indicate AM or PM): _______________________________ ________________________________
If requested course(s) full, alternate choice: ________________________________
PARENT/GUARDIAN INFORMATION
MEDICAL
Are there any medical issues, medications, or allergies you would like us to be aware of? Yes No If yes, please specify below.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
VERIFICATION
I CERTIFY THAT THE INFORMATION ON THIS FORM IS CORRECT.
PARENT/GUARDIAN SIGNATURE: DATE:
STUDENT SIGNATURE: DATE:
The information on this form is collected under the authority of the School Act. Information is used by the District
for Ministry of Education reporting, demographic, enrolment, budget facility and operational analyses. It will be
kept secure and confidential in accordance with the Freedom of Information and Protection of Privacy Act.
OFFICE USE ONLY
COURSES ASSIGNED ENTERED IN MYED NOTES:
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