Student Registration Form Page 4
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4EMERGENCY CONTACT INFORMATION
If parent/guardian not available, contact this person.
1)
Last Name __________________________________________ First Name _______________________________
Male
Female
Self-Identify as ____________
Relationship to student/comment: ____________________
(Circle below, 1 = high, 4 = low)
For Emergency: Priority 1 2 3 4
For School Closure: Priority 1 2 3 4
_ _ _ - _ _ _ - _ _ _ _
_ _ _ - _ _ _ - _ _ _ _
_ _ _ _
_ _ _ - _ _ _ - _ _ _ _
Home No.
Cell No.
ext.
Bus. No.
If parent/guardian not available, contact this person.
2)
Last Name __________________________________________ First Name _______________________________
Male
Female
Self-Identify as ____________
Relationship to student/comment: ____________________
(Circle below, 1 = high, 4 = low)
For Emergency: Priority 1 2 3 4
For School Closure: Priority 1 2 3 4
_ _ _ - _ _ _ - _ _ _ _
_ _ _ - _ _ _ - _ _ _ _
_ _ _ _
_ _ _ - _ _ _ - _ _ _ _
Home No.
Cell No.
ext.
Bus. No.
Emergency Dismissal: (Grades 6 – 8 only)
Remains at School for Lunch (Grades K – 8 only)
Upon dismissal, proceed home as usual
Yes
No
Remain, pending parental instruction
ADDITIONAL STUDENT INFORMATION:
(if required by the school)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Proof of Literacy Test Results Received: Yes No
FOR SECONDARY SCHOOL USE ONLY:
(To be completed for students entering Secondary School on or after September 1999)
Previous Community Service Hours completed outside Halton DSB: _______ hours
Yes
No
Grade 10 Literacy Test successfully completed
(Please provide proof of results)
Please note that this information and any other personal information about your son/daughter is collected, retained, used
and disclosed pursuant to sections 28, 29, 30, 31 and 32 of the Municipal Freedom of Information and Protection of
Privacy Act for the purpose of fulfilling the Board’s responsibilities as set out in the Education Act, Regulations and
Ministry of Education Policies, Procedures, Standards and Guidelines. Opportunities will be provided to update the
personal information collected annually. Any questions with respect to the personal information collected should be
directed to the Principal of the School.
I certify that the information given on this form is correct.
Parent/Guardian Signature: ____________________________________
Date: _______________________
(or student if 18 years of age or older)
This information will be shared with Halton Student Transportation Services for the provision of home to school transportation.
Revised June2015
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