Custodian Declaration Parents Kingsway College
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11200 Leland Road, Oshawa, ON L1K 2H4, Canada
Tel: 905-433-1144 Fax: 905-433-1156
Form 5: Custodian Declaration (Parents)
admissions@kingswaycollege.on.ca
Student Information:
Student's Full Name
Citizenship
Date of Birth
Gender
(DD/MM/YYY)
Male
Female
Address where student will reside in Canada
Parent(s)/Guardian(s) Information:
Parent/Guardian 1
Parent/Guardian 2
Full Name
Date of Birth (DD/MM/YYYY)
Home Address
Telephone Number
E-mail Address
Custodian Information:
Status in Canada
Date of Birth (DD/MM/YYYY)
Canadian Citizen or
Permanent Resident
Full Name
Current Residential Address
Telephone Number
E-mail Address
My/our child will reside:
With the appointed custodian,
In the school residence, or
With another person _________________________ (Please provide first and last name),
________________________ (Relationship to student)
I/We, __________________________ and __________________________ (names of parent(s)/guardian(s) of the said student,
during the student's stay at Kingsway College. I have made the necessary agreements for the care and support of the
said student such that custodian should act in place of me/us, the parents. By signing this custodian agreement, I/we
affirm that I am/we are satisfied that the above appointed custodian resides within a reasonable distance of my/our
child's intended residence and school, and will be able to fulfill his/her obligations as a custodian in the event of an
emergency.
Signature of parent/guardian (1): ___________________________________________________ Date: __________________________
Signature of parent/guardian (2): ___________________________________________________ Date: __________________________
Sworn before me at ______________________ (City),
in the province of ______________________ (Province/territory),
______________________ (Country) if applicable.
This _____ day of _____ (month), ________ (year).
Signature of notary: ___________________________________________________
Official Seal of Notary Public
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