GEORGE BROWN COLLEGE

REQUIRED INFORMATION FOR REGISTRATION INTO

GEORGE BROWN COLLEGE DUAL CREDIT PROGRAM:

Student First and Last Name

Student Middle Initial
Date of Birth (Month /DATE/Year)
Student Email Address
Home Address
Apt/Unit
Postal Code
Home Phone
Alternate Phone
Emergency Contact Name
Relation to Student
Emergency Contact Number
Student Identifying Gender  Male  Female
DUAL CREDIT COURSE NAME
Student OEN Number
Name of Current Secondary School
Contact Teacher at Secondary School
Contact Teacher Email Address
Contact Teacher School Phone Number/Ext.
Credits Earned to Date
Have you been identified through an Identification,  YES  NO
Placement, and Review Committee (IRPC) process?
Do you have a current Individual Education Plan  YES  NO
(IEP)?
Have you at any time taken a leave from high school?  YES  NO
Are you in an SHSM Program?
 YES  NO
If yes, provide name:
 YES  NO
Are you a First Generation student? (If yes, your parents did not complete a college, university or
apprenticeship program in Canada)
 Co-op Teacher  SHSM Teacher  Student Success
Who selected you for the program?  Subject Teacher  Guidance Counsellor  Parent
 Other
How did you hear about the Dual Credit program?
Have you taken a Dual credit course  YES  NO
before? If yes, please indicate name of the course and college
 YES  NO
Have you applied to College? If yes, please indicate the name of the college and the program name

Student Signature Date

(if student is 18 years of age or older)

Parent/Guardian Signature Date

(if student is under 18 years of age)
 Dual Credit Program Consent Form

Image Release

I hereby grant to George Brown College (the “College”) the right and permission to reproduce, use, exhibit, display,
broadcast, distribute and create derivative works of images of me taken [insert date], for use in connection with the
activities of the College or for promoting, publicizing or explaining the College or its activities. This grant includes, without
limitation, the right to publish such images in the College newspaper, alumni magazine, and PR/promotional materials,
such as marketing admissions publications, advertisements, fundraising materials, and any other College-related
publications.

These images may appear in any of the wide variety of formats and media now available to the College and that may be
available in the future, including but not limited to print, broadcast, videotape, CD-ROM, DVD, and electronic/online
media.

Office of the Registrar

FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT

The personal information on this form is collected under the legal authority of the Ontario College of Applied Arts and
Technology Act 2002. The information is used for the administrative and statistical purposes of the College including but
not limited to, Admissions, Registration and maintaining records, as well as Awards and Scholarships; Alumni and College
Foundation administration functions and/or the Ministries or Agencies of the Government of Ontario and the Government
of Canada. This information is being collected under Section 39 (2) and Section 42 of the Freedom of Information and
Privacy Act of Ontario. If you have any questions or concerns related to the Freedom of Information and Privacy please
contact the FOI Coordinator for the College at 416-415-5000 ext. 4646

This information is used for the administrative and statistical purposes of the College and/or Ministries and Agencies of
the Government of Ontario and the Government of Canada.

All registrants must comply with George Brown College’s Code of Conduction and Policies
www.georgebrown.ca/policies

I have read the above statements and I hereby authorize the release of all records related to my registration, attendance
and academic progress to the aforementioned as well as my Parent/Guardian and Secondary School Representative as
stated below.

I have read the foregoing and fully understand the contents of this release form.

Student Name

Student Signature (or enter initials) Date

Parent/Guardian Signature (If student is under Date

18 years of age, enter guardian's initials)

Students: Please provide your email address below so that the Dual Credit staff at George Brown College can send you
important updates about your schedule, timetable and other course information.

Email address:
□ By checking this box, I authorize the above-mentioned parties to contact me for the purposes of program follow-up and
research relating to the Dual Credit program.

P. O. Box 1015, Station B, Toronto, Ontario, Canada M5T 2T9. 416-415 -2000 www.georgebrown.ca
Please 'Save' and submit completed form to: [email protected]
 Statement of Understanding
Dufferin-Peel CDSB & George Brown College Dual Credit Program
The Dual Credit Program offered at George Brown College requires me to spend a considerable amount of time working and
learning outside of my home school as a college/secondary school student. I will represent my school in a responsible manner and in
accordance with my school's Code of Conduct Policy.

I understand that I must follow all the rules of the Dual Credit Program:

I will:
 attend regularly and be punctual both at my home school, at George Brown College and (if applicable) at bus pick-up locations;
 if absent from class, report my absence to my instructor/teacher, at both the college and secondary school, before the start of the
day;
 complete all required assignments, tasks and tests;
 abide by the rules of George Brown College including appropriate behaviour and respect for persons and property; George
Brown College expectations will be outlined within the first week of the program;
 be required (if applicable) to wear safety shoes and will be required to wear other prescribed clothing for this program (e.g.
personal protective equipment) as directed by the instructor;
 carry my student ID with me and be prepared to present it to the bus driver and/or teachers/college instructors as requested;
 abide by the rules of the transportation organization and act responsibly on the bus/taxi/public transportation or my travel
privileges may be withdrawn;
 abide by Health and Safety regulations at George Brown College;
 work co-operatively and communicate in a positive manner with all instructors/teachers and peers.

I understand that:
 George Brown College instructors, coordinators, administrators and staff from George Brown College, Dufferin-Peel CDSB,
and my secondary school may as require, mutually share student information as related to the Dual Credit program (including
student attendance and academic performance, code of conduct issues and student Dual Credit application information).
Information shared may be disclosed to parents or guardians (if student is under the age of 18) upon their request;
 if I have an Individual Education Plan, I am responsible for accessing the college’s Student Accessible Services in order to
understand and receive the support services provided by the college;
 if I do not use the busing or transportation provided, I will be responsible for arriving punctually at George Brown College on the
arranged class dates;
 supervision will not be provided on the bus/public transit. The bus company and/or public transit can refuse service for
inappropriate behaviour;
 if I elect to travel as a passenger in a peer's personal or family vehicle, the district school board/college provide no insurance
coverage;
 travel insurance is not provided while traveling to/from the college. Students are encouraged to purchase Student Accident
Insurance available online at a nominal cost at www.insuremykids.com
 I must declare to my home school and college any medical condition which may seriously affect my participation in the program.
It is strongly recommended by the district school board/college that students obtain additional personal medical/accident
insurance as deemed necessary;
 Dufferin-Peel CDSB will not be held responsible for any liability or medical expenses arising out of participating in this program.
I understand that failure to comply with the above conditions/rules may result in my removal from the program and loss of academic credits.

______________________________________________
Student Printed Name

______________________________________________ _______________________________________
Student Signature Date

______________________________________________
Parent/Guardian Printed Name (if student is under 18 years of age)

______________________________________________ ________________________________________
Parent/Guardian Signature (if student is under 18 years of age) Date

One copy of this signed statement is to be retained with the secondary school, one copy is to be retained by the college, one copy to be retained by
the central board office and one copy is to be distributed to the student or, if the student is under 18 years of age, to the parent/guardian.
 MEDIA CONSENT FORM

SCHOOL: ______________________________________ SCHOOL YEAR: 2020-2021

To: Parent(s)/Guardian(s)/Student:

Schools cooperate with the media and other organizations, within reason, to promote the school board,
schools, programs and student accomplishments. However, we recognize that there are instances where a
parent/guardian may not wish their child photographed or recorded.

I hereby give the Dufferin-Peel Catholic District School Board and/or College and its employees
and agents:

(1) Permission to film/photograph/videotape or make an audio or digital recording of myself for purposes
related to my College Dual Credit course;

(2) The perpetual and non-exclusive right and license to use my image, my name and/or a quote from me
about or a description of my involvement in a work education program in any of the media communications
(i.e. print, audio, television, social media, online) promoting dual credit and experiential learning programs
produced by or on behalf of the Dufferin-Peel Catholic District School Board and/or College without payment
to me;

(3) Consent under the Freedom of Information and Protection of Privacy Act to use and disclose my image,
my name and/or a quote from me about or a description of my participation in any of the media
communications (i.e. print, audio, television, social media, online) promoting experiential learning
programs of the Dufferin-Peel Catholic District School Board and/or College.

Please be advised that all or portions of the work referred to above will become part of the media
organization's database and may be adapted for other educational or non-educational applications,
productions, broadcast, re-broadcast, published, exhibited, reproduced, and/or distributed in various media
formats to a number of markets.

To: The Dufferin-Peel Catholic District School Board

I HAVE READ AND UNDERSTAND THE INFORMATION PROVIDED ON THIS FORM. I VOLUNTARILY GIVE THE
DUFFERIN-PEEL CATHOLIC DISTRICT SCHOOL BOARD CONSENT TO INCLUDE MY CHILD OR ME IN THE MEDIA
COVERAGE AND ITS SUBSEQUENT USE DISCLOSURE AS DESCRIBED ABOVE.

I further understand that this consent is valid for the current school year and may be withdrawn by me at any
time, upon written notice. This Consent form meets the requirements of the Municipal Freedom of Information
and Protection of Privacy Act and the Education Act for the disclosure of personal information.

I CONSENT TO THE ABOVE: I DO NOT CONSENT TO THE ABOVE:

_________________________________ ___________________________________ _______________________

Name of Student (Please Print) If over 16 years of age, Signature of Student Date

_________________________________ ___________________________________ _______________________

Name of Parent/Guardian (Please Print) Signature of Parent/Guardian Date

Media Consent Form

 REMINDER:
ATTACH
CREDIT
COUNSELLING
SUMMARY
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