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Dufferin-Peel Catholic District School Board(1)

VIEWS: 76 PAGES: 4

									                                       Dufferin-Peel Catholic District School Board
                              Student Registration and Information Form – Secondary School

                                                  Office use only         Year: (Circle one) 1 2 3 4 5
  School:
   Academic Transcript of Marks                            Identified as an Exceptional Student
   Application for Direction of School Support/            IEP Documentation
    Lease                                                   Immunization Certificate or Statement of Medical
   Birth Certificate                                         Exemption
   Citizenship/Immigration/Visa Student Verification       Internet Agreement
   Confirmation of Pupil Eligibility (GF008.1)             Medication Forms
   Community Hours to Date:            (proof required)  Most Recent Report Card
   Course Selection Form                                   Newcomer Reception/Assessment
   Custody Order (if applicable)                           OEN Verified:
   Dufferin-Peel Student ID#: ___________________  Proof of Residence (e.g. lease or sales agreement,
   ESL/ELD at Previous School                               phone bill, etc.)
   Exchange of Information Form                            Secondary School Literacy Diploma Requirement
   Faith Formation Fee                                     Start Date
   First Entry Date to Secondary in Ont. ____________  Student Activity Registration Fee
   Flex Boundary
PLEASE PRINT
Student’s Legal Names

Surname:                                                      First Name:                                   Middle Name:

Student’s Preferred Names:  Same as Legal Names, or

Surname:                                                      First Name:                                  Middle Name:

Gender:        Female         Male                                                Birthdate:
                                                                                                 Year                    Month                     Day

Previous school attended:                                                Tel #: (     )                 Address:

Last day attended at previous school:                                     Previous District School Board:
                                               Year     Month      Day

If the student is entering from outside of Ontario, please indicate name of
                                                                                                             Province/Country

Does this student have sibling(s) in this District School Board? Yes No                               If yes:  Elementary  Secondary

If yes, provide full names:

Does this student have sibling(s) in another District School Board? Yes No

If yes, state name of District School Board:

Is this student Roman Catholic or Catholic of the Eastern Rite Catholic Church? Yes                               No

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, and will be used for the Ontario Student Record and for administrative purposes. Questions
about collection may be directed to the Principal of the School or the FOI Officer at the Catholic Education Centre, 40 Matheson Blvd. West, Mississauga,
Ontario L5R 1C5. (Tel. No. 905-890-1221 or 1-800-387-9501.)


                                                                     Page 1                                         GF 008 S
                                                                                                                    Revised 2009 July 16
Medical Condition(s)/Alert:




Student’s Country of Birth:                                                  If Canada, Province of Birth:

Arrival Date (into Canada):                                    Expiry Date (if applicable):
                              Year            Month      Day                                      Year        Month        Day
If arrived within the past five years, complete the ‘Confirmation of Pupil Eligibility . . .’ form (GF008.1).

Status in Canada: (Check one)  Canadian Citizen        Permanent Resident                        Temporary Resident
                               International Student on Visa                                      Refugee
Country of Last Residence:                                               Country of Citizenship:

Has this student ever been away from school for any period of time? Yes                  No

If yes, indicate the date from:                                 to:
                                  Year        Month      Day          Year        Month         Day

Please indicate the reason for school interruption:


VOLUNTARY SELF-IDENTIFICATION: For the purposes of supporting First Nation, Métis and Inuit student
achievement objectives of Dufferin-Peel and the Ministry of Education, and of reporting student achievement to the
Ministry of Education and the Education Quality and Accountability Office, I / we choose to voluntarily self-identify
my/this child ancestry as:

 First Nations            Inuit               Métis          First Nation Métis and Inuit Ancestry

Language(s) spoken by student:
                                          First Language       Spoken at Home             Remark:
                                          First Language       Spoken at Home             Remark:
                                          First Language       Spoken at Home             Remark:


Student’s Address:
                           Number                               Street                             Unit Type (e.g. Apt.)         Unit
                          #
                                                                                                      (   )
                 City                                           Postal Code                                     Phone #

Mailing Address (if different from above):
Please indicate if this student:          lives in a group home        has recently enrolled in a Section 23 program
                                          lives independently of parent or guardian

Is this a temporary residence?           Yes          No 

If yes, provide address of permanent residence:

If yes, specify the occupancy date of your permanent residence.
                                                                              Year        Month
                                                                              Day

                                                               Page 2
                              Special Education / English Language Learners (ELL)
Special Education:

Does this student have special education needs? Yes         No
Does this student have specialized equipment? Yes No
In your previous school/board, was this student involved in special education programs and/or services? Yes         No
Does this student have an Individual Education Plan (IEP)?     Yes     No
Has this student been identified as an exceptional student, through the Identification Placement Review Committee
(IPRC)? Yes No
If yes, has this student had her/his annual IPRC review? Yes No
English Language Learner (ELL):
 In your previous school/board, did this student receive ESL/ESD services? Yes No If Yes, circle stage: 1 2 3 4

                                                  Suspension/Expulsion

1. Are you, or the student being registered, currently serving a suspension?                                Yes     No
2. Are you, or the student being registered, currently participating in a program for suspended students? Yes       No
3. Are you, or the student being registered, expelled from any school and, if yes, where were you
   placed upon expulsion?                                                                                   Yes     No
4. If you are a student of 16/17 years of age, have you withdrawn from parental control?                    Yes     No

                                                 Sharing of Information
If the student is currently not in a Dufferin-Peel Catholic District School, I/we agree that the Dufferin-Peel Catholic
District School Board may contact my child’s former school to collect information for purposes consistent with the
Board’s legislated responsibilities and authority.

Yes    No If no, please state reason: ____________________________________________________________


Signature of Parent/Guardian (or Student if 18 years of age or older / 16/17 and withdrawn from parent consent )

Note:
1. A school transfer could affect eligibility to participate in sports. "Any student who attended another high school
   (anywhere) in the previous 12 months must be approved by the ROPSSAA Transfer and Eligibility Committee prior
   to participating in ROPSSAA activities."

2. Admission to this Secondary School is considered to be conditional pending receipt and review of the student’s
   records from his/her previous school. Falsifying information on this form will rescind the admission to this Secondary
   School.

                                                  Custody Information
Who has legal custody? Both parents          Father only         Mother only      Other

Are there any special arrangements pertaining to access/visitation? Yes       No

If yes, please specify, and provide copy of custody order.



                                                          Page 3
                                                 Contact Information
                                                                                       Catholic: Yes No
1st Parental/Guardian Contact:

                                                                                        Speaks English
Title                     First Name                        Last Name


Relationship to Student         Emergency Priority (Circle one): 1 2 3

Address:  Same as student or

Home Phone:  Same as student or (         )                       Business Phone: (   )                  Ext.


Cell Phone: (   )


2nd Parental/Guardian Contact:                                                         Catholic: Yes No

                                                                                        Speaks English
Title                     First Name                       Last Name


Relationship to Student         Emergency Priority (Circle one): 1 2 3


Address:  Same as student or

Home Phone:  Same as student or (         )                       Business Phone: (   )                  Ext.


Cell Phone: (   )


Emergency Contact (other than parent/guardian):                                        Gender: Female
                                                                                       Male
 Title                       First Name                      Last Name

Relationship to Student            Emergency Priority: (Circle one) 1    2   3          Speaks English

Address:  Same as student or

Home Phone:  Same as student or (         )                       Business Phone: (   )                  Ext.


Cell Phone: (   )

                                                      Signatures


Signature of Parent/Guardian                                                           Date
(or Student if 18 years of age or older / 16/17 and withdrawn from parent consent)


Signature of Principal/Designate

								
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