School District #36 (Surrey)

School District #36 (Surrey)

Student Registration Form

Insert Your School Name Here

**PLEASE PRINT CLEARLY**

STUDENT

Pupil No. ______Gender ______(M/F)

Legal Last Name ______

Legal First Name ______

Usual Last Name ______

Preferred First Name ______

Middle Name ______

Birth Date ______Age ______

Proof Of Age ______

Home Phone No. ______Unlisted ____ (Y/N)

PROPERTY ADDRESS

Street # & Name ______Apt # ______

City ______Prov. ______

Postal Code ______X-Boundary______(Y/N)

Proof Of Address ______

Mailing Address Same as Property Address? ______(Y/N)

If Different… ______

______

PREVIOUS SCHOOL/DISTRICT

District ______

Name of School ______

Province/Country ______School Language ______

IMMIGRATION / MISCELLANEOUS

Country of Birth ______

City ______Province ______

Citizen of ______

Immigration Status ______

Entry Date ______

Expiration Date ______

Language ______

Language at HOME ______

ABORIGINAL ANCESTRY INFORMATION

r YES r NO

r  Inuit

r  Metis

r  Non-Status

r  First Nation Status-Off Reserve

r  First Nation Status-On Reserve

Band of Residence Name ______DIA# ______

**Information package to be given to families who indicate Yes.

OTHER FORMS & INFORMATION (Office Use ONLY)

Internet Access ______(Y/N)

Permission to Walk Home ______(Y/N)

Release Student Data

Outside of the district ______(Y/N)

Media Release ______(Y/N)

Care Card # on File ______(Y/N)

Request for Records complete______(Y/N)

Course Selection ______(Y/N)

Volunteer Driver Form ______(Y/N)

Medical Alert Complete ______(Y/N)

EMERGENCY CLOSURE

Call Emergency Contact

Call Home/Parent

Retain at School

Send Home

Send to Daycare

Interpreter Required ______(Y/N)

Locker Assigned ______(Y/N)

PARENT / GUARDIAN

Custody ______Living with ______Court Access ______

Relationship ______

(Parent: Mother/Father or Guardian)

Last Name ______

First Name ______

Living with Student ______(Y/N) Emergency Contact ______(Y/N)

Address if Different ______

Speaks English _____ (Y/N) Other Language: ______

Work Tele. ______Cellular ______

Home Tele. ______E-Mail ______

Relationship ______

(Parent: Mother/Father or Guardian)

Last Name ______

First Name ______

Living with Student______(Y/N) Emergency Contact ______(Y/N)

Address if Different ______

Speaks English _____ (Y/N) Other Language: ______

Work Tele. ______Cellular ______

Home Tele. ______E-Mail ______

SIBLINGS

Pupil No. 1. ______2. ______3. ______

Name ______

Relationship ______

______Age ______Grade ______Age ______Grade ______Age ______Grade

Gender ______(M/F) ______(M/F) ______(M/F)

School ______

EMERGENCY CONTACTS

Last Name ______

First Name ______

Relationship ______(Relative/Neighbour)

Home Tele. ______Work Tele. ______

E-Mail ______Cellular ______

Last Name ______

First Name ______

Relationship ______(Relative/Neighbour)

Home Tele. ______Work Tele. ______

E-Mail ______Cellular ______

Last Name ______

First Name ______

Relationship ______(Relative/Neighbour)

Home Tele. ______Work Tele. ______

E-Mail ______Cellular ______

Last Name ______

First Name ______

Relationship ______(Relative/Neighbour)

Home Tele. ______Work Tele. ______

E-Mail ______Cellular ______

MEDICAL

Doctor’s Name: ______Phone:______Dentist: ______Phone: ______

Care Card #: :______

Allergies / Health Conditions: ______

Life Threatening: ______(Y/N) Other: ______

Other Health Factors: ______

TRANSPORTATION

As per Board Policy does this student qualify for Bussing? ______(Y/N)

PROGRAMS

Has the student been tested for:

Special Education ______(Y/N) English as a Second Language ______(Y/N) Gifted ______(Y/N)

Kindergarten: Prefer AM ______PM ______Full Day ______

Number of Registration Form OR Date & Time: ______Copy of Immunization Record ______(Y/N)

NOTES

I certify that the information on this form is correct.

______

Parent / Guardian Signature Date

The information on this form is collected under the authority of the School Act. Information is used by the District for Ministry of Education reporting; demographic, enrolment, budget facility and operational analyses. It will be kept secure and confidential in accordance with the Freedom of Information and Protection of Privacy Act.