Fillable School Registration Form (Page 2 of 3) in pdf

School Registration Form Page 2

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EGISTRATION

ORM

School District No. 40

Emergency Contact (other than parent) 1

Emergency Contact (or daycare) 2

Name:

Relationship to student:

Home Phone #:

Mobile Phone #:

Student Medical Health Information

Doctor name:

Dentist name:

Phone #:

Student’s CareCard Number:

Copy of immunization record attached?

Yes

Medical Alert:

Yes

No If yes, specify:

Please list any health concerns, e.g., vision, hearing, allergies, chronic illness, etc.:

Sibling Information

First/last name:

Brother

Sister

Birthdate (mm/dd/yyyy):

First/last name:

Brother

Sister

Birthdate (mm/dd/yyyy):

First/last name:

Brother

Sister

Birthdate (mm/dd/yyyy):

First/last name:

Brother

Sister

Birthdate (mm/dd/yyyy):

Name and Address of Previous School:

Copy of last report card:

Yes

Copy of transfer from previous school:

Yes

The information on this form is collected under the authority of the School Act, Sections 13 and 79. The information provided will be used for educational

program and administrative purposes, and when required, may be provided to health services, social services or support services as outlined in Section 79

(2) of the School Act. The information collected on the form will be protected in accordance with the provisions of the Freedom of Information and

Protection of Privacy Act. If you have any questions about the information recorded on this form, please contact the School Administration.

I certify that all information in this registration form is true and complete. I also acknowledge that it is my responsibility to

ensure that I notify the school regarding any changes to this information. Please sign upon presentation of this form at your school.

Signature of Parent/Guardian:

Date:

Office Use Only

Assigned to:

Grade:

Division:

Teacher:

Student Registration Form Received by: