Student Verification Form

School Name/# John Fraser Secondary School Pupil Number 760869 OEN 290-768-787 Grade S1 Hfm 9C
Student Information
Legal Last Name Sanaullah Legal First Name Safa Middle Name
Usual Last Name Sanaullah Preferred First Name Safa DOB 2008-02-25 Gender Female
Residential Information
Apt # Street Number and Name 2386 Poplar Cres Municipality Mississauga
Prov. ON Postal Code L5J 4H3 Home Phone (647) 293-8718 Unlisted? Yes X No
General Information
Immigration Status Landed Immig/Perm Res Was English first language student learned at home ? YES X NO
Language student speaks at home Urdu , English
Country of Birth India Province / Territory if Canada 1st Entry Date to Canada 2008-12-06
Voluntary And Confidential Self Identification First Nation Métis Inuit
Parent/Guardian Information
Custody Both Parents Living With Both Parents
Relationship Mother Last Name Ansari First Name Safiah Aslam
Living with student X Yes No Copy of Correspondence Yes X No Same address as student X Yes No
2386 Poplar Cres Home Phone (647) 293-8718 Unlisted? Yes X No
Address Mississauga, ON
Cell Phone (647) 293-8718
L5J 4H3
Email [email protected]
Speaks English X Yes No Avail at Work? X Yes No Work Phone # () - Ext.
Relationship Father Last Name Sanaullah Shukrullah First Name Mohammed
Living with student X Yes No Copy of Correspondence Yes X No Same address as student X Yes No
Address 2386 Poplar Cres Home Phone (647) 799-0719 Unlisted? Yes X No
Mississauga, ON
L5J 4H3 Cell Phone (647) 799-0719
Email [email protected]
Speaks English X Yes No Avail at Work? X Yes No Work Phone # () - Ext.
Relationship Last Name First Name
Living with student Yes No Copy of Correspondence Yes No Same address as student Yes No
Address Home Phone Unlisted? Yes X No
Cell Phone
Email
Speaks English Yes No Avail at Work? Yes No Work Phone # Ext.
Emergency Contacts
Name Salma Siddiqui Relationship Aunt Home # () - Cell # (416) 275-1186 English X Yes No
Name Sameera Khan Relationship Emergency Contact Home # () - Cell # (647) 708-1769 English X Yes No
Name Relationship Home # Cell # English Yes No
Health Information
Health Factor Life Threatening ? Plan of Care Required? Medication required at school
Yes No Yes No Yes No
Health Factor Life Threatening ? Plan of Care Required? Medication required at school
Yes No Yes No Yes No
Health Factor Life Threatening ? Plan of Care Required? Medication required at school
Yes No Yes No Yes No
Health Factor Life Threatening ? Plan of Care Required? Medication required at school
Yes No Yes No Yes No
Siblings
Last Name Sanaullah First Name Saad DOB 2004-06-18 School Roberta Bondar Public School
Last Name Sanaullah First Name Sidrah DOB 2009-12-22 School Roberta Bondar Public School
Last Name First Name DOB School
Last Name First Name DOB School
Any requested changes in the shaded areas will require substantiating documentation. Please contact your child's school for further
instruction.

Parent/Guardian Name (please print) Parent/Guardian Signature Date

Student Name ( if 12 or older) (please print) Student Signature ( if 12 or older) Date

Municipal Freedom of Information and Protection of Privacy Act: Personal Information on this form is collected under the legal authority of the Education Act, R.S.O. 1990, c.E-2, as
amended. This information will be used for the Ontario Student Record and administrative purposes. Questions regarding this collection should be directed to the Principal or Freedom of
Information Co-ordinator, Peel District School Board, 5650 Hurontario Street, Mississauga, Ontario, L5R 1C6. Tel: 905-890-1010, ext. 2019.

Revised June 24, 2013