Filed in OSR Retention: E + 5 yrs (E = retired student)
DETAILS OF PREVIOUS SCHOOLING
OEN (Ontario Education Number) if known
Public Catholic Private Home Schooled Out of Province/Country
LANGUAGE OF LAST SCHOOL ATTENDED
DATE OF ENTRY TO FIRST SECONDARY SCHOOL – MM/DD/YYYY
English French English and French Other (Specify):
Has student attended a Grand Erie school before? Yes No
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
ADDITIONAL INFORMATION (if applicable)
SELF-IDENTIFICATION (if applicable) this is voluntary/optional
English French Other (specify):
Six Nations of the Grand River
Mississaugas of the Credit
First Nations Métis Inuit
Language currently spoken at home:
CITIZENSHIP/STATUS original Citizenship and Immigration documents must be produced if student is new to the Grand Erie District School Board
Study Permit/Visitor Record
Diploma Status/Minister’s Permit
DATE OF ENTRY TO CANADA (if applicable) – YYYY/MM/DD
COUNTRY OF CITIZENSHIP
COUNTRY/PROVINCE OF BIRTH
PREVIOUS PROVINCIE/COUNTRY OF RESIDENCE
EMERGENCY CONTACT/MEDICAL INFORMATION
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)
I have obtained the consent of the person(s) listed above to have their name and telephone number used for emergency purposes
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
For Students Residing on Six Nations of the Grand River: I give permission for student achievement information (e.g.,
name, grade, achievement) to be provided to elementary schools that the student attended for the purpose of improving
elementary programming. Yes No
I understand that student personal information (e.g., name, D.O.B.) and achievement data is released by the board to
Indigenous Services Canada in order to fulfil our agreements with respective Bands. Yes
For Students Residing on the Mississaugas of the Credit First Nation (MCFN): I give permission for student
information (e.g., name, grades, attendance, discipline, IEPs, IPRC notices and decisions, etc.) to be provided to the MCFN
Education Director in confidence to help MCFN support its young people. Yes No
I authorize MCFN to initiate/attend IPRC reviews/meetings to advocate for better student supports. Yes No
Authorization may be revoked at any time in writing by letter or email.
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 or STUDENT IF 18 YRS OR OLDER:
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