Fillable STUDENT REGISTRATION FORM

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STUDENT REGISTRATION FORM

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The STUDENT REGISTRATION FORM form is 4 pages long and contains:

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  • 138 check-boxes
  • 144 other fields

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File type: PDF

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STUDENT REGISTRATION FORM
School Name: _________________________________________ Date: _______________
FOR OFFICE USE ONLY
Date of Entry ____________________________ Homeroom ___________________________ Grade ______________
Home School ____________________________ OEN Number __________________________ ESL ________________
Baptismal Record
q Birth Certificate q Birth Registration q Immigration Document q Passport q
Verification of Documentation for School Registration (from Welcome Centre) q Other q
________________________________
Language(s) Spoken in the Home
q ______________________ First Language q
________________________________
PREVIOUS SCHOOL ATTENDED
School Name ______________________________________ School Board ____________________________________
City ____________________________________________ Date Left _______________________________________
Phone Number _____________________________________ Fax Number _____________________________________
MEDICAL INFORMATION
Medical Emergencies - Anaphylaxis? Daily Medication Needed? If YES, ADDITIONAL FORMS MUST BE FILLED OUT.
Medical Condition Please note: Serious medical alerts, chronic illnesses, allergies and treatment
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Doctor's Surname _______________________________________ First Name __________________________________
Doctor's Phone Number __________________________________
FIRST NATIONS, METIS OR INUIT ANCESTRY - (Voluntary and Confidential Self Identification)
q First Nations (living on or off Reserve)
q Metis
q Inuit
CITIZENSHIP - If country of birth is other than Canada, please complete this section:
Birth Country __________________________________ Arrival Date (into Canada) _____________________________
Status in Canada (Please check one of the following.) Signature from Welcome Centre _________________________
Canadian Citizen q Convention Refugee q Refugee Claimant q Permanent Resident q
Study Permit (Fee-paying Student) q Other Visa q ______________ Parental Work/Study Permit q
_________________
Verification Document Provided (from above)____________________ Expiry Date ______________________________
Country of Last Residence ___________________________ Country of Citizenship ______________________________
PLEASE PRINT ALL INFORMATION
Revised Jan. 2020
Information gathered on First Nation, Métis, Inuit ancestry will help the DSBN learn more
about indigenous student achievement and allocate resources and supports to improve
learning and student success. Any email address provided by you may be used to
communicate with you. Some of these messages may be commercial in nature. Questions
about the collection of this information should be directed to the Principal of the school.
STUDENT INFORMATION
Legal Surname _________________________ First Name _____________________ Middle Name ___________________
Preferred Surname __________________________________ Preferred First Name _______________________________
Date of Birth ______ / ______ / ______ Gender Male q Female q
(day/month/year)
Date of Birth Verification (Please check one of the following.)
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signature
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SIBLING INFORMATION Sibling Information: (If the student has siblings in this school, please indicate the name.)
1) ________________________________ 3) ________________________________
2) ________________________________ 4) ________________________________
STUDENT HOME ADDRESS Verification of home address (utility bill, rental agreement, etc.) No q Y es q Type
_____________
Number _______ Street _________________________ Unit No. ____________ Unit Type: Apt. q Unit q Suite q
Additional Delivery Information ______________________________________________________________________
City/Town _____________________________ Township ________________________ Postal Code _______________
Home Phone No. (Landline)________________________ Listed q Unlisted q
TRANSPORTATION INFORMATION
If this student will be staying with a sitter or child care provider on a consistent basis, please complete the following information for use by transportation:
Pick Up Address (before school)
Number _______ Street __________________________ Unit No. ___________ Unit Type: Apt.
q Unit q Suite q
City/Town ____________________________ Township _______________________ Postal Code ______________
Additional Delivery Information ______________________________________________________________________
Phone Number of Contact ____________________________________________________
Drop off Address (after school)
Number _______ Street _________________________ Unit No. ____________ Unit Type: Apt.
q Unit q Suite q
City/Town ____________________________ Township _______________________ Postal Code ______________
Additional Delivery Information ______________________________________________________________________
Phone Number of Contact ____________________________________________________
Definitions: Emergency Priority: The person to be contacted in case of an emergency.
School Closure Priority: The person to be contacted in case of school closure.
School Emergency Dismissal Procedures (Please check one of the following)
Keep at school
q Send home by bus or taxi q Dismiss immediately q
(until designated pick up) (if normal means of transportation)
Send home with older sibling
q Sibling's Name____________________________________ Grade __________________
(If the student is JK, they cannot be sent home with an older sibling.)
_____________________________ _____________________________ _____________________________
Signature of Mother Signature of Father Signature of Legal Guardian
PARENT/GUARDIAN INFORMATION
Parent q Stepparent q Foster Parent q Legal Guardian q
Emergency Priority: 1 2 3 4 5 (Please circle one choice: 1 = high, 5 = low)
School Closure Priority: 1 2 3 4 5 (Please circle one choice: 1 = high, 5 = low)
Surname _________________________ First Name ___________________ Mrs. q Ms. q Miss q Mr. q Dr. q
Address: (Complete if different from student’s home address.)
Number _______ Street _________________________ Unit No. ____________ Unit Type: Apt.
q Unit q Suite q
Additional Delivery Information ______________________________________________________________________
City/Town _____________________________ Township ________________________ Postal Code _______________
LEGAL CUSTODY Yes
q No q LIVES WITH STUDENT Yes q No q ACCESS TO RECORDS Yes q No q
ACCESS TO STUDENT Yes q No q RECEIVES MAIL Yes q No q
Place of Employment ___________________________________ Business Number __________________ Ext. ________
Home Phone Number (Landline)______________________ Unlisted q
Cell Phone Number _______________________
Primary Email Address (CASL) _____________________________
Alt 2 Email Address (CASL) _______________________________
It is important you select the correct Emergency Priority and Closure Priority in the contact information on the following
pages. This is to ensure the correct person is contacted in an emergency situation. Throughout the parents/guardians and
contacts, please use #1 only once, #2 only once, #3 only once, etc.
2 of 4
Alt 1 Email Address (CASL) _______________________________
Subscribeq Unsubscribeq
Subscribeq Unsubscribeq
Subscribeq Unsubscribeq
Refer to pg. 4
CASL CONSENT.
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PARENT/GUARDIAN INFORMATION
Parent q Stepparent q Foster Parent q Legal Guardian q
Emergency Priority: 1 2 3 4 5 (Please circle one choice: 1 = high, 5 = low)
School Closure Priority: 1 2 3 4 5 (Please circle one choice: 1 = high, 5 = low)
Surname ___________________________ First Name _________________ Mrs. q Ms. q Miss q Mr. q Dr. q
Address: (complete if different from student’s home address)
Number _______ Street ___________________________ Unit No. __________ Unit Type: Apt.
q Unit q Suite q
Additional Delivery Information _______________________________________________________________________
City/Town _________________________________ Township _______________________ Postal Code ____________
LEGAL CUSTODY Yes
q No q LIVES WITH STUDENT Yes q No q ACCESS TO RECORDS Yes q No q
ACCESS TO STUDENT Yes q No q RECEIVES MAIL Yes q No q
CONTACT INFORMATION
(if a parent cannot be contacted during the day - local contact)
Emergency Priority: 1 2 3 4 5
(Please circle one choice: 1 = high, 5 = low)
School Closure Priority: 1 2 3 4 5 (Please circle one choice: 1 = high, 5 = low)
Surname __________________________ First Name ___________________ Mrs. q Ms. q Miss q Mr. q Dr. q
Relationship to the student ___________________________________________________________
(i.e., Guardian, Grandparent, Stepparent, Foster Parent, Sitter, Aunt, Uncle, Brother, Sister, Friend)
Address
Number _______ Street _____________________________ Unit No. ________ Unit Type: Apt.
q Unit q Suite q
Additional Delivery Information ______________________________________________________________________
City/Town _________________________________ Township _______________________ Postal Code ____________
GUARDIAN Yes
q No q LIVES WITH STUDENT Yes q No q ACCESS TO RECORDS Yes q No q
ACCESS TO STUDENT Yes q No q RECEIVES MAIL Yes q No q
Place
of Employment _______________________________________ Business Number ________________ Ext. ______
Home Phone Number (Landline) ______________________ Unlisted q
Cell Phone Number _______________________
CONTACT INFORMATION
(if a parent cannot be contacted during the day - local contact)
Emergency Priority: 1 2 3 4 5
(Please circle one choice: 1 = high, 5 = low)
School Closure Priority: 1 2 3 4 5 (Please circle one choice: 1 = high, 5 = low)
Surname __________________________ First Name ___________________ Mrs. q Ms. q Miss q Mr. q Dr. q
Relationship to the student ___________________________________________________________
(i.e., Guardian, Grandparent, Stepparent, Foster Parent, Sitter, Aunt, Uncle, Brother, Sister, Friend)
Address
Number _______ Street _____________________________ Unit No. ________ Unit Type: Apt.
q Unit q Suite q
Additional Delivery Information ______________________________________________________________________
City/Town _________________________________ Township _______________________ Postal Code ____________
GUARDIAN Yes
q No q LIVES WITH STUDENT Yes q No q ACCESS TO RECORDS Yes q No q
ACCESS TO STUDENT Yes q No q RECEIVES MAIL Yes q No q
Place of Employment _______________________________________ Business Number ________________ Ext. ______
Home Phone Number (
Landline)______________________
Unlisted
q
C
e
ll
Phone
Number
_____________________
3 of 4
Place of Employment _______________________________________ Business Number _________________ Ext. ______
Home Phone Number (Landline)_________________________ Unlisted
q
Cell Phone Number ___________________
Primary Email Address (CASL) _____________________________
qSubscribe qUnsubscribe
Alt 1 Email Address (CASL) _______________________________
qSubscribe qUnsubscribe
Refer to pg. 4
CASL CONSENT.
Alt 2 Email Address (CASL) _______________________________ qSubscribe qUnsubscribe
5
5
5
5
5
5
FREEDOM OF INFORMATION
- in school or DSBN publications (e.g., newsletters, yearbook, annual report etc)? q Yes q No
- to the media? (radio, television, newspapers including their online and social media channels)?
q Yes q No
- in school or DSBN Electronic Publications, (including webpages and social media)?
q Yes q No
INTERSCHOOL ATHLETIC PROGRAM
USE OF BOARD TECHNOLOGY
STUDENT REGISTRATION INFORMATION: FOR OFFICE USE ONLY
Activity Fee _____________________________________ Number ___________________________________
Yearbook Fee ____________________________________ Combination _______________________________
Workbook Fee ___________________________________
Serial Number ______________________________
Grad Fee __________________________ Total ________
PLEASE PRINT ALL INFORMATION
In order for the school to release personal information, we must comply with the provisions of the Municipal Freedom of
Information and Protection of Privacy Act, 1990.
If your child is under the age of 18 years, do you consent to the student's name, photograph, image and/or audio recordingand/or
accomplishments being released:
To continue receiving electronic communications from your child's school and the DSBN, Canada's Anti-Spam Legislation (CASL)
requires that you provide us with your consent. This requirement came into effect on July 1, 2014. Your preference will be saved in
the DSBN student database.
Personal information contained on this form and any other correspondence relating to involvement in Board programs is collected
under the authority of s.170, s.190, s.264, and/or s.265 of the Education Act and Sabrina’s Law and in accordance with the Municipal
Freedom of information and Protection of Privacy Act (MFIPPA). It will be used in the Ontario Student Record and for registration,
administrative, communication, educational and reporting purposes. The information may be shared with other educational
support workers employed by the District School Board of Niagara or with other employees to carry out their job duties or with
providers of student transportation or child care. In addition, the information may be used for matters of health and safety or
discipline and is required to be disclosed in compelling circumstances or for law enforcement or in accordance with any other Act.
Medical information will be shared with those transporting students in order to ensure their health and safety.
According to the Administrative Procedure entitled Permission to Participate in Interschool Athletic Program, student
athletes must complete a Permission to Participate Form for each sport. This form includes medical and personal information
needed by a coach in case of emergency. The District School Board of Niagara recommends an annual medical examination for
students who participate in interschool sports. These forms, or copies of the forms, should be readily accessible by the coach at all
times. This includes all practices and games.
The use of District School Board of Niagara's digital technology is a resource and a technological tool for lifelong learning.
According to Administrative Procedure "4-02 Digital Technology Use by Students", the District School Board of Niagara expects
schools to implement the administrative procedure relative to the proper application of Digital Citizenship Guidelines. In order for
students to access the Internet and Intranet services both students and parents/guardians will complete and sign an "I.T. Digital
Citizenship Agreement" provided by the school which is an agreement by students to abide by all directions established by the
District School Board
of Niagara's "Digital Technology Use by Students" policy. Students who have not completed and submitted
the "I.T. Digital Citizenship Agreement" will be prohibited from using the Board's Digital Technological resources.
4 of 4
CASL CONSENT
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STUDENT REGISTRATION FORM

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Completed 22 January 2021

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