PRAIRIE ROSE SCHOOL DIVISION - école St. Eustache

							                                    PRAIRIE ROSE SCHOOL DIVISION
                              STUDENT REGISTRATION FOR SCHOOL YEAR 2012-2013

Name                                                                                                   Male                Female _______
         (Last)                         (First)                          (Middle) (Circle name used)

Date of birth                                                                     Home telephone no.
                  (month, day, year)                                                                   (listed/unlisted)
Student’s mailing address                                                   _____________________________________
                              (Box no., town/village, postal code)
Address ____________________________________                                        911 Address: ________________________________
         (Legal Land– Section/Twn/Range – street address)

Registered for grade                                         School

School previously attended
                                        (for new students only)
                    Address                                                                                        Phone No.


Father’s name ____________________________________                            Mother’s name ____________________________________
Employing firm ____________________________________                           Employing firm ____________________________________
Cell Number: _____________________________________                            Cell Number: ______________________________________
Business telephone no. ____________________________                           Business telephone no. ____________________________
Email Address: ___________________________________                            Email Address: ___________________________________
** Legal guardian’s name                                                                    Occupation
Employing firm                                     Home telephone no.                                   Business telephone no.
Student living with     both parents          / mother        / father        / guardian       / other
List siblings (school-aged and pre-school age) by order of grade:
                   Usual First Name              Grade            Sex                         Birthdate (Month, Day, Year)




In case of emergency please contact: (if parents and/or guardian is not home)

                                                            (name, telephone no.)

Name of bus driver

In case of a blizzard your child(ren) can billet at the following residence(s): (state family’s full name and telephone no.)




Can you billet students? Yes              No             How many students?
If car pools are used for transportation, list the families involved:
        Permission to publish student photographs


        From time to time we celebrate students’ accomplishments/interests by reproducing their pictures in the newsletter
        or on the school/division web page. We request parents’ permission to print students’ pictures in these cases.
        I _______________________________________, the parent/legal guardian of the student named below
        give the school/school division permission to reproduce their photograph in our newsletter or web page with
         their first name only, as identification.
                                        Name of parent/guardian __________________________________
                                                                       (please print)

        Signature: ______________________________________              Date: ____________________________
        Full name of student ____________________________________________




I attest that the information provided is the correct information for the above-named student and his/her parent/guardian. Also, the
above-named student is not requesting admission as a result of a suspension/expulsion from another School Division.



Parent/Legal Guardian                                                                    Date

The information requested on this form is required to enable school staff to educate and care for our students as prescribed in the
    Public Schools Act, Prairie Rose School Division policy manual, and the rules and regulations of this school. If you have any
    questions related to the information requested on this form please contact the principal. Please be advised that some of the above
    information may be released to the Public Health Nurse Department as per the Personal Health Information Act.