PARENT/GUARDIAN INFORMATION
No Relation to student: (Check one )Living with student Yes
No Mother Father GrandparentEmergency Contact Yes
No GuardianSpeaks English Yes Aunt Uncle
No Homestay Other Family ServicesWilling to Volunteer Yes
______________________________
Who has legal custody?
No ___________________________________ Same as Student’s Address Yes Legal Last Name:
___________________________________ If not living with student provide address: _________________
Legal First Name:
_________________________________ Home Telephone #: __________________________________________________
____________________________________ Mobile Phone #: _____________________________________
E-mail Address:
______________________ Business Phone # if available at work: ___________________
VISA/Work/Study Permit Number:
SIBLING INFORMATION (School age siblings 5-18 yrs.) (Check one)
__________________________________________ Male Female Birth Date: ____________________
1. Name:
__________________________________________ Male Female Birth Date: ____________________
2. Name:
__________________________________________ Male Female Birth Date: ____________________3. Name:
EMERGENCY CONTACT INFORMATION: OTHER THAN PARENT
___________________________________ Legal First Name: ___________________________________
Legal Last Name:
_______________________________________ Address: __________________________________________
Relationship:
No Work Phone #: ______________________________________
Does this person speak English? Yes
_____________________________________ Mobile Phone #: _____________________________________Home Phone #:
EMERGENCY CONTACT: OUT OF PROVINCE / COUNTRY (Call in the event of a Natural Disaster)
___________________________________ Legal First Name: ___________________________________Legal Last Name:
Does this person speak English? Yes No
__________________________ Work Phone #: ______________________________________
Legal relationship to student:
_____________________________________ Mobile Phone #: _____________________________________Home Phone #:
STUDENT MEDICAL HEALTH INFORMATION
Allergies and Health Conditions (Check one)
________________________________________ Care Card #: Allergies/Conditions Yes No
_______________________________________
Is an Immunization Record attached? If yes, What?
No Life Threatening? Yes Yes No
_____________________________________________What?
The information on this form is collected under the authority of the School Act, Sections 13 and 79. The information provided will be used
for educational programs and administrative purposes, and when required may be provided to health services, social services or support
services as outlined in Section 79(2) of the School Act. The information collected on this form will be protected consistent with the Freedom of
Information and Protection of Privacy Act. If you have any questions about the information recorded on this form, please contact the School
Administrator.
I certify that the above information is correct and valid as of this date. I understand that the provision of false information may lead
to my child no longer being able to attend the assigned school.
________________________________ Date: __________________ Verified by: _________
Parent / Guardian Signature:
_________________________________ Date: ______________________________________Administrator’s Signature:
DD-MMM-YYYY
DD-MMM-YYYY
DD-MMM-YYYY
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