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
Contact #1
Relationship: _
First Name: _
Last Name: _
Home Phone: Cell:
Work phone:
Email:
Lives with Student: □ Yes □ No
Contact #2
Relationship: _
First Name: _
Last Name: _
Home Phone: Cell:
Work phone:
Email:
Lives with Student: □ Yes □ No
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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