Student Registration Form Page 2

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MEDICAL INFORMATION:
Yes 
No 
._ _ _ _ _ _ _ _ _ _ _
Health Card No
Immunization Record Complete
(Version No.)
(optional but recommended)
(see yellow insert from Regional Municipality of Halton)
Medical Conditions:
If your child has significant health factors of which the school should be aware, please describe the condition(s) below.
Life Threatening
Yes
_______________________________________________________________________________________
No
Yes
No
_________________________________________________________________________________________________
Yes
_______________________________________________________________________________________
No
SIBLING INFORMATION:
(if the student has brothers or sisters in this school, please indicate)
Last Name
First Name
1)
__________________________________________
_______________________________________
2)
__________________________________________
_______________________________________
3)
__________________________________________
_______________________________________
ABORIGINAL STUDENT SELF-IDENTIFICATION: (please check off one of the boxes below, this is voluntary)
First Nation Ancestry
 Inuit Ancestry
 Metis Ancestry
Fill in the section below, ONLY if country of birth is other than Canada:
Legal Documents Required to make any changes
Birth Country ________________ Arrival Date ____________
Status in Canada ___________________
Verification _________________ Expiry Date ____________ Country of Last Residence ___________________
Country of Citizenship to be completed for ALL
students:
Country of Citizenship___________________________________ Province of Birth ___________________________
(If born in Canada)
Languages Spoken (if other than English)
1) ______________________________________________
First Language
Spoken at Home
2)______________________________________________
First Language
Spoken at Home
HOME ADDRESS:
Proof of Address Required
Number ________ Street _______________________________________________________________
Apt. No. ________________
Unit No. _____________________
Suite No. __________________
City/Town ________________________
Province _____________
Postal Code ________________
__ __ __ - __ __ __ - __ __ __ __
HOME PHONE NUMBER:
Unlisted
MAILING ADDRESS:
(if different from home address
)
Number ________ Street _______________________________________________________________
Apt. No. ________________
Unit No. _____________________
Suite No. __________________
Rural Route No. __________
Post Office Box No._____________
General Delivery No. ________
City/Town ________________________
Province _____________
Postal Code ________________

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