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Registration Form 2011-2012

This registration form collects student information including name, date of birth, address, parent/guardian details, emergency contacts, medical information, program choice, transportation, and international student status if applicable. It is multi-page with sections for student, parent/guardian, emergency, medical, program, transportation, and international student details. Signatures are required from parents/guardians to authorize medical attention and certify information is correct.

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wolfvilleschool
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78 views3 pages

Registration Form 2011-2012

This registration form collects student information including name, date of birth, address, parent/guardian details, emergency contacts, medical information, program choice, transportation, and international student status if applicable. It is multi-page with sections for student, parent/guardian, emergency, medical, program, transportation, and international student details. Signatures are required from parents/guardians to authorize medical attention and certify information is correct.

Uploaded by

wolfvilleschool
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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2011-2012 REGISTRATION FORM

SCHOOL: Wolfvile School

Date of Enrolment (Month/Day/Year): School Attended Last Year (if different):

PROGRAM INFORMATION* [Choose one of the following]


English Program Early French Immersion (Begins in Primary) English Program with Intensive French (Begins in Grade 7) Late French Immersion (Begins in Grade 7)

*Note: Contact school administration for assistance completing this section, if needed.

STUDENT INFORMATION
LEGAL NAME (as listed on birth certificate, passport or immigration papers) Last: First: Middle: Preferred: Date of Birth: Month _______ Day _______ Year _______ Gender: Female Male PSM # (Completed by Office): Civic Address (Street, Apt): Mailing Address (Street, Apt)(if different from civic address): Home Phone: Proof for Date of Birth (must be presented to Office): Birth Certificate Passport Immigration Papers Grade: Out of Area? (Completed by Office): Yes No City/Town, Province & Postal Code: Mailing Address - City/Town, Province & Postal Code: Students Cell Phone:

PARENT / GUARDIAN INFORMATION


PARENT/GUARDIAN 1 Name (First/Last): Relationship: Civic Address (if different from student): Civic Address (Street, Apt): City/Town, Province & Postal Code: Home Phone: Work Phone: Cell Phone: Email Address: Language Comprehension: PARENT/GUARDIAN 2 Name (First/Last): Relationship: Civic Address (Street, Apt): City/Town, Province & Postal Code: Home Phone: Work Phone: Cell Phone: Email Address: Language Comprehension:

English

French

English

French

Language Most Often Spoken in the Home: Arabic English French Mikmaq Gaelic Other, please specify ______________________________

Language Most Often Spoken in the Home: Arabic English French Mikmaq Gaelic Other, please specify ______________________________

CUSTODY ARRANGEMENTS [Appropriate documentation should be provided]


Are special custody arrangements requested for this student at school? Description/Details (including any special instructions): Yes No

Revised: April 2011

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2011-2012 REGISTRATION FORM


EMERGENCY CONTACT(S) [Other than Parent(s)/Guardian(s)]
Contact 1 Name (First/Last): Relationship: Home Phone: Work Phone: Cell Phone: Language Comprehension: English French Language Most Often Spoken in the Home: Arabic English French Mikmaq Gaelic Other, please specify ____________________ Contact 2 Name (First/Last): Relationship: Home Phone: Work Phone: Cell Phone: Language Comprehension: English French Language Most Often Spoken in the Home: Arabic English French Mikmaq Gaelic Other, please specify ____________________ Contact 3 Name (First/Last): Relationship: Home Phone: Work Phone: Cell Phone: Language Comprehension: English French Language Most Often Spoken in the Home: Arabic English French Mikmaq Gaelic Other, please specify ____________________

MEDICAL INFORMATION
Does your child have any potential, life-threatening medical conditions? Yes No If YES*, please check one or more of the following: Allergies (Severe Allergic Reaction) Anxiety/Depression Asthma Diabetes Epilepsy/Seizure Heart Condition Flight Risk (due to diagnosed medical condition) Other potential, life-threatening medical condition, please specify: ___________________________________ *Note: Please contact a school official to complete an Individual Health/Emergency Care Plan. Please specify any medications as well as medical response and instructions that may be necessary:

Provincial Health Card No.:

Doctors Name: Yes

Doctors Phone: No

Does your child have special needs which may require individual programming? If YES, please specify:

If your child requires medical attention and a school official is unable to contact parent(s)/guardian(s), emergency contact(s) or family physician, I/we give consent to have a school official take my/our child to the nearest medical facility. X __________________________________________________________________ Parent/Guardian Signature

SELF-IDENTIFICATION [Completion of this section is voluntary and confidential.]


Parents/Guardians and/or students are encouraged to self-identify. By doing so, this enables the Department of Education and School Boards to have a greater awareness of the diversity of the student population and the communities served and to better meet the educational needs of students. ABORIGINAL IDENTITY For the purpose of this form, Aboriginal Peoples are persons who consider themselves to be North American First Nations or Inuit. Is this student considered to be an Aboriginal person? If YES, please check the group that best applies: Status On-Reserve Status Off-Reserve Non-Status On-Reserve Non-Status Off-Reserve Band (please identify): Acadia First Nation Glooscap Paqtnkek Wekaqmaq
Revised: April 2011

Yes

No Inuit Other, please specify ________________________________

Annapolis Valley First Nation Bear River First Nation Eskasoni Indian Brook First Nation Membertou Millbrook Pictou Landing First Nation Potlotek Wagmatcook Non-Nova Scotia Band, please specify ________________________________
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2011-2012 REGISTRATION FORM


ANCESTRY Parents/Guardians and/or students are encouraged to self-identify. By doing so, this enables the Department of Education and School Boards to have a greater awareness of the diversity of the student population and the communities served and to better meet the needs of students. This section refers to the ethnic or cultural origins of the students ancestors from either/or both sides of the family. Ethnic or cultural ancestry should not be confused with nationality. Please select one from the following list: Acadian/Acadien* descent African descent East Asian descent European descent Asian descent Middle Eastern descent Other, please specify _________________________________ *Note: For those students entitled to attend a French school, contact a School Official to complete the necessary forms.

SIBLINGS
Please list all children in your family who attend school. If you require additional space, please attach a separate page. Name (First/Last) Grade School

TRANSPORTATION [To be completed by Parents, if known or by the School Office]


Special Needs Transportation required? School Bus Bus Route: AM Route: AM Stop Location: Bus Driver: Eligibility: Eligible Administration Permission Reason for Administration Override: Not Eligible Public Bus Pass Yes No Walk PM Route: PM Stop Location: Bus Driver: Bus Type: School Bus Public Bus Pass

ALTERNATE BUSSING INFORMATION [To Be Completed By Office] AM Street: Contact Name (First/Last): PM Both

Under special circumstances, some children may require alternate pick up and/or drop off locations to/from school and a location other than their home residence. Within reason, the school will make arrangements to accommodate these requests.

City, Province & Postal Code: Contact Phone:

INTERNATIONAL STUDENT INFORMATION


Country of Origin: Please select one of the following choices: Walk-in Student Nova Scotia International Student Program (NSISP) Participant Exchange Student (HS Only) Health Insurance: Yes No Parent has Employment Authorization Parent has Student Authorization Parent is a Permanent Resident

I/we certify that all of the information on this registration form to be correct. X ______________________________________________________________________ _______________________________________________________________________
Revised: April 2011

Parent/Guardian Signature Date


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