VANIER SECONDARY
SCHOOL DISTRICT NO. 71 (COMOX VALLEY)
Student Registration Form
CURRENT GRADE
TODAY’S DATE
(Admission Date)
LEGAL NAME:
________________________
_____________________
(LAST)
___________________
(FIRST)
____________________
(MIDDLE)
(USUAL NAME IF
DIFFERENT)
STUDENT’S ADDRESS: __________________________
____ CITY: ________________POSTAL CODE:
DATE OF BIRTH: ________________ (DD-MMM-YYYY)
PLACE OF BIRTH:
SEX:
COPY OF BIRTH CERTIFICATE PROVIDED?
M
F
LAST SCHOOL ATTENDED: ________________________________ City: _______________
ABORIGINAL ANCESTRY: Yes (
STATUS: On Reserve (
) No ( )
)
Off Reserve (
)
Metis (
)
Y
N
Province:
BAND NAME & NUMBER:
Inuit ( )
Non-Status (
)
FIRST LANGUAGE SPOKEN: ________________________________ LANGUAGE MOST USED:
PARENT/GUARDIAN INFORMATION
Student Lives With:
(Mother&Father, Mother&Step-Father, Joint Custody, Guardian,
etc.)
Parent #1 Name: _________________________________
Relationship: ______________
Phone:
Address: _________________________________City: _______________Postal Code: ___________
Cell:
Employer: _______________________________________
Phone: ___________________
E-mail:
Parent #2 Name: _________________________________
Relationship: ______________
Phone:
Address: _________________________________City: _______________Postal Code: ___________
Cell:
Employer: _______________________________________
Phone: ___________________
E-mail:
Parent #3 Name: _________________________________
Relationship: ______________
Phone:
Address: _________________________________City: _______________Postal Code: ___________
Cell:
Employer: _______________________________________
Phone: ___________________
E-mail:
Parent #4 Name: _________________________________
Relationship: ______________
Phone:
Address: _________________________________City: _______________Postal Code: ___________
Cell:
Employer: _______________________________________
E-mail:
Phone: ___________________
PARENT INVOLVEMENT IN SCHOOL: Our policy is to encourage involvement of a child’s parents in their education. It is the registering parent’s
responsibility to ensure that the parent/guardian information section of the registration form is complete and accurate. If legal papers and/or court documents exist
regarding custody, guardianship or limitations placed in the involvement of one parent please be sure to submit a copy with t he registration form. If concerns exist
regarding the involvement of a parent, please inform the administration.
COURT ORDER IN EFFECT?
YES or NO
SIBLINGS in SD 71? ____________________________________
School has copy?
At our School?
YES
YES
or
or
NO
NO
EMERGENCY INFORMATION: In an emergency (earthquake, illness or accident, impassable bridges) the school requires the name and phone
number of at least two contacts that your child may be released to when the guardian is not available.
Name: _________________________
Relationship:
____________
Phone: __________
Cell:
Name: _________________________
Relationship:
____________
Phone: __________
Cell:
Name: _________________________
Relationship:
____________
Phone: __________
Cell:
Name: _________________________
Relationship:
____________
Phone: __________
Cell:
MEDICAL INFORMATION:
Care Card No. ______________________
DOCTOR: ________________________
PHONE:
DENTIST: ________________________
PHONE:
SPECIAL MEDICAL INSTRUCTIONS: (medical alerts, allergies, etc.)
LEARNING NEEDS (Learning Assistance, Modified Program, etc. )
OFFICE USE ONLY
Student No
Registration Date
______
____
Assigned to Grade _________
____
(First Day of Attendance)
Advisor Group No.
STUDENT RECORDS:
_____
Requested
X-Boundary
Received
School District #71 (Comox Valley)
GP Vanier Secondary School
CONSENT FOR RELEASE OF INFORMATION
I, _______________________________________________ hereby consent to the release of the
(please check one)
□
(parent/guardian)
or
□
(adult student)
following information:



Student Records (reports, letters, legal documents e.g.: copy of birth certificate, medical cards, court orders) , Permanent
Educational Records
Learning Assistance file (if applicable)
Confidential File (e.g. Psychology Reports Speech and Language Reports, Physiotherapy/Occupational Therapy Reports,
Dr.’s letters, etc.) if applicable - Attention “Receiving” School Secretary please forward the confidential file to
Student Services Dept.
For the purpose of providing an educational program for the following student:
This information is considered confidential and will be treated accordingly.
Student Name: _________________________________________________
Date of Birth:
_________________________________________________
School/Agency releasing information: ______________________________________________
______________________________________________
______________________________________________
______________________________________________
School receiving information:
School District #71 (Comox Valley)
School Name: GP Vanier Secondary School
Address: 4830 Headquarters Road, Courtenay BC V9J 1P2
Phone: 250-338-9262
Fax: 250-338-1308
Email: [email protected]
Date: ____________________
Signature of: ___________________________________
□
(parent/guardian) or
check one)
□
(adult student)
(please check one)
Parent/Guardian or (Adult Student) Address:
______________________________________________________________________________
______________________________________________________________________________
Relationship to student: ____________________________
Parent Signature
____________________________
(please