Waterloo Catholic District School Board - St. Louis Adult ...

Waterloo Catholic District School Board

Student Registration Form ? Continuing Education

Adult Day School Correspondence International Languages School To Work

Students who attended high school this year must present a Principal-to-Principal Form. Adult Day School students must be 18 years of age or older on the first day of classes. Correspondence students must be 16 years of age or older and have their high school's approval. International Language students must specify the course code and have their high school guidance signature on the back of

this form.

Confidential - Please Print

LEGAL NAME A.

Last Name

First Name

Middle Name

LEGAL NAME IN FINAL YEAR OF HIGH SCHOOL (if different)

Gender: Male Female Date of Birth

Year:

Month:

Day:

B. Are you attending or did you attend a secondary school this school year? Yes No

C.

Last Secondary School Attended

Last Date Attended

In City

High School Graduate

Yes No

D. Does student require an EPIPEN? Yes No Does student have any serious or potentially life-threatening conditions? Yes No

MEDICAL ALERT, CONDITION or DISABILITY

Related Notes or Remarks

E. Was student born in Canada? Yes No

IF NO, specify Birth Country:

Status in Canada:

Permanent Resident Canadian Citizen Refugee

Employment Permit Student Visa

Other Visa

IF YES, in which Canadian province?

First Arrival in Canada:

Year/ Month/ Day

Expiry Date:

Year/ Month/ Day

Country of Last Residence

Student's First Language:

Number & Street

Address

F.

Home Phone

Email Address

Emergency Contact

G.

Home Phone

Last Name

Work Phone

Country of Citizenship

Spoken at Home Main Language at home

Apt.

City

Postal Code

Cell

First Name

Cell

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Rev: July 14

I. VOLUNTARY ABORIGINAL STUDENT SELF-IDENTIFICATION: Student is ... First Nation (Status,Non-Status) M?tis Inuit ...(check one)

The information above is collected under the authority of the Education Act, s 8.1(1) and in accordance with the Municipal Freedom of Information and Protection of Privacy Act. Information provided will help the Ministry, school boards and schools develop programs and services for First Nation, M?tis and Inuit students; Provide accurate and reliable information on enrolment, literacy, numeracy, and graduation rates; Determine whether current programs are meeting students' needs; Provide information to inform future policy and program decision-making. Questions or concerns about should be addressed to your school principal.

Personal information contained on this form is collected pursuant to the Education Act s. 265 and the Municipal Freedom of Information and Protection of Privacy Act. Information will be used for educational planning and communications and to establish the Ontario Student Transcript (OST). Limited information may be disclosed beyond the Board for purposes such as:

- OSBIE, the school board insurer (in case of accident or witness to an accident) - The Public Health Unit - Hospital or health officials (in case of an emergency) - WCDSB Newcomer Centre (if appropriate)

Any questions related to the collection/use/disclosure of information should be directed to the principal. This form is kept until superseded.

In case of an emergency I give permission for the school to contact the name and telephone numbers provided above as `Emergency Contact'.

I verify that the information on this form is true and correct. I understand that it is my responsibility to keep the school advised of any change in the above information as soon as possible.

Date:

Signature of Student:

FOR SCHOOL USE ONLY - COUNSELOR to Complete. For INTERNATIONAL LANGUAGES , complete only part 1.

1. OEN #:

Counselor's Signature:

Home School:

Courses:

2. Fee: $

Ontario Transcript:

Yes No

Credit Counseling Summary: Yes No

Comments:

ID#:

(See Fee Structure Sheet)

Principal to Principal Transfer Request Form: Yes No Core E Teacher Referral Yes No ESL Teacher Referral Yes No Proof of ESL Level 6 Level 7

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Rev: July 14

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