Fillable Student Registration and Attestation Form - Confidential AP

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Student Registration and Attestation Form - Confidential AP

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January 2020 AP 4270 FS-20-H
Student Registration and Attestation Form - Confidential
FS-20-H
AP 4270
STUDENT
INFORMATION – PLEASE PRINT
Legal Surname:
Legal
First Name:
P
referred Surname:
Preferred First Name:
Legal Middle Name: Gender: □
Male □
Female
Home Phone: □
Unlisted Date of Birth
(year-month-day):
Please list student’s siblings in this school:
Is the student currently expelled from any school or school board?
□
Yes
□
No
Parent/Guardian Registration Checklist
In all instances, ORIGINAL documentation must be presented.
□ Completed Registration Form
□ Proof of Student's Age (present one original document from the list below)
Canadian Birth Certificate / Birth Registration Card
Canadian Citizenship Card / Certificate / Passport
Permanent Resident Card / Confirmation of Permanent Residence
Letter of Admission from the Waterloo Region District School Board International Admissions Office
□ Proof of Address (present one original document from the list below)
Current Utility Bill (water, hydro, gas, home phone, cable, internet)
Government forms (i.e. Service Canada documents)
Lease / Purchase Agreement / Tax Bill
Note: We cannot accept a Driver's license as a Proof of Address.
□ Proof of Immunization
Submit directly to the Region of Waterloo Public Health at https://e-immunization.regionofwaterloo.ca/ or call 519-575-4400
□ Proof of Custody/Guardianship Arrangements
Children must live with their parent(s) unless legal documentation supports an alternate living arrangement
If no formal court ordered custody agreement exists and the student is living with someone other than a biological parent, an
agreement outlining the relationship between the parent and the adult caregiver that details the responsibilities and
arrangements between the adults is required (TUITION FEES MAY APPLY)
□ Proof of Education
Elementary students: Please bring the most recent report card
Secondary students: Please bring the most recent transcript, report card or credit summary report (if available) and Principal to
Principal Transfer Form (if from a Waterloo Catholic District School Board Secondary School)
Notify school at time of registration if your child is registered currently in a specialized program such as Specialist High Skills
Major (SHSM), International Baccalaureate (IB), French Immersion (FI), English as a Second Language (ESL)
Provide a copy of your child’s supporting documents for identified resource assistance, if applicable
Information on this Registration Form is collected under the legal authority of the Education Act and its regulations, and in accordance with the Municipal Freedom of
Information and Protection of Privacy Act. Information collected on this form will be used to establish the Ontario Student Record (OSR) and for other student and
educational related purposes, such as registration, administrative, communication, data reporting and transportation. The information may also be retained independently
of the OSR for Ministry of Education reporting purposes. Questions or concerns about the collection of data on this form should be directed to the Principal of the school or
the Freedom of Information, Privacy and Records Information Management Officer, Waterloo Region District School Board.
January 2020 AP 4270 FS-20-H
STUDENT ADDRESS
INFORMATION
Home Address:
Number Street Apt #
City / Town / Village / Municipality Province Postal Code
Mailing Address: Same as home address? □ Yes □ No If NO, please complete below
Number Street City / Town / Village / Municipality Province Postal Code
TRANSPORTATION ARRANGEMENTS FOR ELIGIBLE STUDENTS
The Board determines transportation eligibility. To determine if the student is eligible, visit Bus Planner (https://bpweb.stswr.ca/). If a
student is eligible for board-funded transportation, indicate where the student will be picked up and dropped off:
□ Picked up from Home □ Dropped off at Home □ Picked up from Caregiver □ Dropped off at Caregiver □ Special Education Eligible
Pick up Address:
Number Street City / Town / Village / Municipality Province Postal Code
Drop off Address:
Number Street City / Town / Village / Municipality Province Postal Code
PREVIOUS SCHOOL
INFORMATION
Name of Previous School:
Previous School Address: Language of Instruction:
City / Town / Village / Municipality Province
Previous School Board: Grade:
Last Date of Attendance: Reason for Transfer:
Did the student ever attend a Waterloo Region District School Board School in the past (including International Languages)? □ Yes □ No
If yes, name school(s):
STUDENT LANGUAGE, CITIZENSHIP AND IMMIGRATION
INFORMATION
Country of Birth:
If Canada, Province of Birth:
Citizenship
:
Date Arrived in Canada:
First Language: Language Spoken at Home:
STUDENT MEDICAL
INFORMATION
(If this section is applicable to the student, there may be additional forms to be completed)
Allergies or Health Concerns:
Are any of the noted health concerns life threatening?
□
Yes
□
No
Does the student require an epi-pen? □
Yes
□
No
VOLUNTARY FIRST NATION, METIS AND INUIT SELF IDENTIFICATION
If you wish to declare that your child is a First Nation, Metis or Inuit person, please check one of the following boxes.
□ First Nation □ Metis □ Inuit
SPECIAL EDUCATION / IEP/ IPRC / ESL / ELD INFORMATION
Does your child receive any special education assistance (elementary or secondary)? □ Yes □ No
If YES, please provide details:
Has your child previously received English as a Second Language (ESL) or English Literacy Development (ELD) assistance? □ Yes □ No
If YES, please provide details:
January 2020 AP 4270 FS-20-H
PARENT / LEGAL GUARDIAN / EMERGENCY CONTACT INFORMATION
Living With
□ Both Parents □ Mother Only □ Father Only □ Legal Guardian □ C.A.S/F&CS □ Other:
Custody
□ Both Parents □ Mother Only □ Father Only □ Joint □ Legal Guardian □ C.A.S/F&CS □ Other:
If joint custody checked, please indicate schedule: □ Weekly □ Bi-Weekly □ Monthly □ Other:
Provide alternate address for joint custody:
Is there a legal document that sets out custody and access to the student?
□ No □ Yes (please provide school with copy of legal document for OSR)
Contact 1 (Contact information for self, if student is 18 years of age or older)
Name: □ Male □ Female
Title (Mr., Mrs., Dr., etc.) Last Name First Name
Relationship to Student: Employer (optional):
Check all applicable boxes Has access to Student: □ Yes □ No □ Legal Guardian □ Receives Mail
□ Has Custody □ Has Access to Records
Emergency/Attendance Contact Priority: □ First □ Second □ Third □ Lives with Student □ Speaks English
Home Number: Priority: (1-3) Business Number: Priority: (1-3)
Cell Number: Priority: (1-3) Email Address:
Address: □ Same as Student’s Home Address □ Address Below:
Number Street City / Town / Village / Municipality Province Postal Code
Contact 2 Name: □ Male □ Female
Title (Mr., Mrs., Dr., etc.) Last Name First Name
Relationship to Student: Employer (optional):
Check all applicable boxes Has access to Student: □ Yes □ No □ Legal Guardian □ Receives Mail
□ Has Custody □ Has Access to Records
Emergency/Attendance Contact Priority: □ First □ Second □ Third □ Lives with Student □ Speaks English
Home Number: Priority: (1-3) Business Number: Priority: (1-3)
Cell Number: Priority: (1-3) Email Address:
Address: □ Same as Student’s Home Address □ Address Below:
Number Street City / Town / Village / Municipality Province Postal Code
Contact 3 Name: □ Male □ Female
Title (Mr., Mrs., Dr., etc.) Last Name First Name
Relationship to Student: Employer (optional):
Check all applicable boxes Has access to Student: □ Yes □ No □ Legal Guardian □ Receives Mail
□ Has Custody □ Has Access to Records
Emergency/Attendance Contact Priority: □ First □ Second □ Third □ Lives with Student □ Speaks English
Home Number: Priority: (1-3) Business Number: Priority: (1-3)
Cell Number: Priority: (1-3) Email Address:
Address: □ Same as Student’s Home Address □ Address Below:
Number Street City / Town / Village / Municipality Province Postal Code
PARENT/GUARDIAN/STUDENT (over 18) ACKNOWLEDGEMENT
I certify that the information that I have provided on this form is accurate. I understand that copies of custody documentation, if
applicable, will be included in the Ontario Student Record (OSR).
Parent/Guardian/Student (over 18) Full Name Signature Date
January 2020 AP 4270 FS-20-H
For School Use ONLY
SCHOOL CHECKLIST FOR STUDENT REGISTRATION
In all instances, ORIGINAL documentation must be presented.
Proof of Age and Immigration Status and Language Information for Funding Purposes
Canadian Birth Certificate/Registration Card
Canadian Citizenship Card/Certificate
Canadian Passport
Canadian Permanent Resident Card
Confirmation of Permanent Residence
Statement/Notice of Live Birth
Letter of Admission from WRDSB International Admissions Office
Country of Birth _______________________
Province/Territory of Birth (if Canada) __________
Parent speaks English Yes No
Was English first language student learned at home
Yes No
Complete this section if the student is a Permanent Resident:
Confirmation of Permanent Residence Date became a P.R.:
Permanent Resident Card (see back of card) Date became a P.R.:
Complete this section if the student is a Canadian Citizen born outside of Canada:
Date of entry is the date that student enters Canada to live, not a short term visit/vacation in Canada taken beforehand
Canadian Passport Original date of first entry to live in Canada:
Canadian Citizenship Certificate Date of Entry Stamp in Passport:
Proof of Address/Residence in Waterloo Region
We cannot accept Driver’s License as Proof of Address
Government Issued Forms
Utility Bill
Bank Statement
Purchase/Lease Agreement
Tax bill
Proof of Custody (where applicable)
Living with custodial parent(s)
Custodial Court Order
Guardianship (Ontario Court Order Transferring Custody)
If there is no Ontario Court Order, ALL the following criteria must be met (check Yes or No) for the child to attend school without tuition fees:
Yes No 1) The student is a Canadian citizen or a permanent resident of Canada.
Yes No 2) The guardian is a member of the student’s immediate family and resides in Ontario in the school board jurisdiction in
which the student wants to attend school.
Immediate Family Relationship (please specify):
Yes No 3) The guardian assumes full responsibility for the care and well-being of the student, and the student will reside with the
guardian throughout the custody period.
Yes No 4) A written agreement is in place between the parents of the student and the guardian that sets out all of the above, as
well as the respective responsibilities of the parents and the guardian. (RETAIN COPY FOR OSR)
Additional Documentation
Report Card Transcript and/or Credit Summary Report (secondary students)
IEP (if applicable) Other Program Documentation
Principal to Principal Transfer Form
I certify that the information contained on this form is accurate and that I have examined and verified the applicable information as
indicated.
Certified by Principal or designate:
Print name Signature
Position Date
This form and the information contained within it will be maintained in the Ontario Student Record.
Retention: E, plus 5 – file in OSR
Legal Last Name
WRDSB Student #
Legal First Name
OEN #
Entry Date
Entry Type
Grade
Class/Homeform
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Student Registration and Attestation Form - Confidential AP

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Completed 3 December 2020

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