Fillable Student Registration and Attestation Form - Confidential FS-19-H

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Student Registration and Attestation Form - Confidential FS-19-H

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January 2019 AP 4270 FS-19-H
Student Registration and Attestation Form - Confidential
FS-19-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
(dd-mmm-yyyy):
Is the student currently expelled from any school or school board?
□
Yes
□
No
Parent/Guardian Registration Checklist
In all instances, ORIGINAL documentation or officially certified true copies 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 International Admissions
□ 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)
Purchase Agreement / Tax Bill
Note: We cannot accept a Driver's License as a proof of address.
□ Proof of immunization
To be submitted directly to the Region of Waterloo Public Health
o Online at https://e-immunization.regionofwaterloo.ca/ or calling 519-575-4400
□ Proof of custody
Children must live with their parent(s) unless legal documentation supports an alternate living arrangement
□ Proof of education
For Elementary students who are currently attending school in Ontario, please bring the most recent report card
For Secondary students who are currently attending or have attended Secondary School in Ontario, please bring the
most recent transcript, report card or credit summary report (if available)
Notify school at time of registration if your child is registered currently in a specialized program such as Specialist
High Skills Major (SHSM) (include sector), International Baccalaureate (IB), French Immersion (FI), English as a
Second Language (ESL) or other programming
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 2019 AP 4270 FS-19-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. 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
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:
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 2019 AP 4270 FS-19-H
PARENT / LEGAL GUARDIAN / EMERGENCY CONTACT
INFORMATION
Is there a legal document that sets out custody and access to the student?
□ No □ Yes (please complete this section and provide school with copy of legal document for OSR)
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:
Living With
□ Both Parents □ Mother Only □ Father Only □ Legal Guardian □ C.A.S/F&CS □ Other:
Contact 1 (Contact information for self, if student is over 18 years)
Name: □ Male □ Female
Title (Mr., Mrs., Dr., etc) Last Name First Name
Relationship to Student:
Please indicate the priority order
Home Number:
Business Number:
Cell Number:
Email:
□ Same as Student’s Home Address □ Address below:
Employer (optional):
Check all applicable boxes
Has access
to Student
□Yes □No
□ Legal Guardian
□ Receives Mail
□ Has Custody
□ Has access to Records
□ Lives with Student
□ Speaks English
Emergency / Attendance Contact Priority
□ First □ Second □ Third
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:
Please indicate the priority order
Home Number:
Business Number:
Cell Number:
Email:
□ Same as Student’s Home Address □ Address below:
Employer (optional):
Check all applicable boxes
Has access
to Student
□Yes □No
□ Legal Guardian
□ Receives Mail
□ Has Custody
□ Has access to Records
□ Lives with Student
□ Speaks English
Emergency / Attendance Contact Priority
□ First □ Second □ Third
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:
Please indicate the priority order
Home Number:
Business Number:
Cell Number:
Email:
□ Same as Student’s Home Address □ Address below:
Employer (optional):
Check all applicable boxes
Has access
to Student
□Yes □No
□ Legal Guardian
□ Receives Mail
□ Has Custody
□ Has access to Records
□ Lives with Student
□ Speaks English
Emergency / Attendance Contact Priority
□ First □ Second □ Third
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 2019 AP 4270 FS-19-H
SCHOOL CHECKLIST FOR STUDENT REGISTRATION (to be completed by School Staff)
In all instances, ORIGINAL documentation or officially certified true copies must be present.
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
□ Letter of Admission from 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 students 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 can not accept Driver’s License as proof of address
□ Government Issued Forms
□ Utility Bill
□ Purchase / Lease Agreement
□ Tax bill
Proof of Custody (where applicable)
□ Living with custodial parent(s)
□ Custodial Court Order
□ Guardianship Agreement
Additional Documentation
□ Report Card □ Transcript and/or Credit Summary Report (secondary students)
□ IEP (if applicable) □ Other Program Documentation
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:
_______________________ _____ ____________________________
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
WRDSB Student #
OEN #
Entry Type
Grade
Class/Homeform
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Student Registration and Attestation Form - Confidential FS-19-H

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Completed 3 December 2020

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