District School Board Ontario North East
    STUDENT REGISTRATION FORM
    Confidential – Please Print
    Student Registration Form
    Page 1 of 4
    (please print)
    For School Use
    :
    Entry Date: _______________________
    Program:
    English
    Grade: _______________________
    O E N: __________________________
    French Immersion
    Independent Study
    STUDENT INFORMATION
    Full Legal Name: _______________________
    ___________________________
    ________________________________
    Last Name
    First Name
    Middle Name(s)
    Preferred Name: ________________________
    ___________________________
    ________________________________
    Last Name
    First Name
    Middle Name(s)
    Gender:
    Female
    Male
    Date of Birth: ______ _____ _____
    Month
    Day
    Year
    Other students in household attending this
    school: (list Name & Relationship to student being
    registered)
    _______________________________________
    _______________________________________
    _______________________________________
    Language(s) spoken at home: _________________________________
    For School Use:
    Proof of Birth:
    Birth Certificate
    Immigration Papers/Card
    Passport
    Province of Birth: _________________
    Birth Country: _________________________
    Country of Citizenship: ________________________
    Name of last school most recently attended
    : ____________________________________________
    City: ____________________________________________
    Has the student ever been registered at a District School Board Ontario North East school:
    Yes
    No
    If
    Yes
    , name of school(s): ___________________________________________________
    Special Education
    : Has the student ever been identified through an IPRC for special education support?
    Yes
    No
    INDIGENOUS SELF-IDENTIFICATION (
    Voluntary)
    Parents/guardians and students over the age of 18 have the opportunity to self-identify as a student of an Indigenous ancestry
    (e.g., First Nations, Métis, Inuit). Self-identification will enable access to services and/or programs listed below. First Nations
    students may self-identify whether living on or off a First Nations’ community. Government identification is not required for self-
    identifying.
    Self-Identification:
    Métis
    Inuit
    First Nation
    First Nation Affiliation: ________________________________
    Have you relocated from a First Nation?
    Yes
    No
    Date of Relocation: __________________________________
    Summary of Programs/Services Offered
    (Not all programs/services are available at all schools)
    ?
    Academic support
    ?
    Aboriginal Youth Liaison Officers
    ?
    Programs and referral services
    ?
    Home-School communication (letters, phone calls, etc.)
    ?
    Monitoring of academic progress and attendance
    ?
    School-wide programs/events (e.g. Aboriginal Day K-12)
    ?
    Early Literacy/Numeracy intervention
    ?
    Homework club
    ?
    Newsletters
    ?
    Cultural Events/Presentations
    ?
    Leadership Conference (Gr. 8-12)
    ?
    Graduation/Scholarship/Bursary post-secondary
    information
    STUDENT HOME ADDRESS INFORMATION
    Proof of Address:
    License
    Utility Bill
    Tax Bill
    Other:________________________
    Apt. No. __________
    House No. ___________
    Street: _____________________________________________________
    City/Town/Twp./Mun. _____________________________________
    Prov. ___________
    Postal Code ________________
    Mailing Address:
    Same as above, OR:
    __________________________________________________
    Box / RR#
    City/Town/Twp/Mun.
    Prov.
    Postal Code ________________
    Home Phone No. _____________________
    Work Phone No. ____________________
    Cell No. ____________________
    Email Address: ___________________________________________________
    (Complete CASL section, p.4, if email provided)

    Student Registration Form
    Page 2 of 4
    (please print)
    PARENT/GUARDIAN INFORMATION
    Legal Documentation is to be provided if
    No Access
    is selected for a parent/guardian listed.
    Emergency contact number is used to show whom to call in the case of emergency and/or school closure.
    Email addresses provided may be used for contact purposes.
    Parent/Guardian
    Last Name : _______________________________
    First Name: ______________________________
    Relationship:
    Mother
    Father
    Step Parent
    Foster Parent
    Legal Guardian
    Other:
    _______________________
    Access to Student
    No Access
    Lives with Student
    Custody
    Emergency Contact #_______
    (i.e. 1
    st
    , 2
    nd
    , 3
    rd
    to be called in emerg.)
    Legal Document(s) Received
    :
    Yes
    No
    Home Phone No. ____________________________
    Cell Phone: ________________________________
    Business Phone: ____________________________
    Place of Employment: ______________________________________
    Email Address: ________________________________________________
    (Complete CASL section, p.4, if email provided)
    Physical Address
    Same as student; OR:
    _________________________________________________________________________________
    Apt + House # or Lot/Conc.
    Street/Road
    City/Town/Twp/Mun.
    Prov.
    Postal Code
    Mailing Address
    Same as physical; OR:
    _________________________________________________________________________________
    PO Box or RR #
    City / Town / Township / Municipality
    Prov.
    Postal Code
    Parent/Guardian
    Last Name : _______________________________
    First Name: ______________________________
    Relationship:
    Mother
    Father
    Step Parent
    Foster Parent
    Legal Guardian
    Other:
    _______________________
    Access to Student
    No Access
    Lives with Student
    Custody
    Emergency Contact #_______
    (i.e. 1
    st
    , 2
    nd
    , 3
    rd
    to be called in emerg.)
    Legal Document(s) Received
    :
    Yes
    No
    Home Phone No. ___________________________
    Cell Phone: ________________________________
    Business Phone: ____________________________
    Place of Employment: ______________________________________
    Email Address: ________________________________________________
    (Complete CASL section, p.4, if email provided)
    Physical Address
    Same as student; OR:
    _________________________________________________________________________________
    Apt + House # or Lot/Conc.
    Street/Road
    City/Town/Twp/Mun.
    Prov.
    Postal Code
    Mailing Address
    Same as physical; OR:
    _________________________________________________________________________________
    PO Box or RR #
    City / Town / Township / Municipality
    Prov.
    Postal Code
    Parent/Guardian
    Last Name : _______________________________
    First Name: ______________________________
    Relationship:
    Mother
    Father
    Step Parent
    Foster Parent
    Legal Guardian
    Other:
    _______________________
    Access to Student
    No Access
    Lives with Student
    Custody
    Emergency Contact #_______
    (i.e. 1
    st
    , 2
    nd
    , 3
    rd
    to be called in emerg.)
    Legal Document(s) Received
    :
    Yes
    No
    Home Phone No. ____________________________
    Cell Phone: ________________________________
    Business Phone: ____________________________
    Place of Employment: ______________________________________
    Email Address: ________________________________________________
    (Complete CASL section, p.4, if email provided)
    Physical Address
    Same as student; OR:
    _________________________________________________________________________________
    Apt + House # or Lot/Conc.
    Street/Road
    City/Town/Twp/Mun.
    Prov.
    Postal Code
    Mailing Address
    Same as physical; OR:
    _________________________________________________________________________________
    PO Box or RR #
    City / Town / Township / Municipality
    Prov.
    Postal Code

    Student Registration Form
    Page 3 of 4
    (please print)
    EMERGENCY CONTACT INFORMATION
    Trusted individuals who may be contacted in an emergency when the parent/guardian cannot be reached.
    1)
    Last Name : __________________________________
    First Name: ___________________________________________
    Relationship to Student: ______________________
    Email Address: ____________________________________________
    Home Phone No. __________________________
    Bus. Phone: ____________________
    Cell Phone: ________________
    2)
    Last Name : __________________________________
    First Name: ___________________________________________
    Relationship to Student: ______________________
    Email Address: ____________________________________________
    Home Phone No. __________________________
    Bus. Phone: ____________________
    Cell Phone: ________________
    TRANSPORTATION ADDRESS INFORMATION
    Transportation eligibility is determined by the Board. If student is eligible for board-funded transportation, indicate where he/she
    will be picked up & dropped off:
    Picked up from home
    Dropped off at home
    Picked up from
    Caregiver
    Dropped off at
    Caregiver
    If student will NOT be picked up from or dropped off at home, enter the caregiver’s information for pick-up/drop-off:
    Pick Up Address:
    Caregiver Name: ______________________________________
    Phone No. ______________________
    ______________________________________________________________________________________________________
    Apt + House # or Lot/Conc.
    Street/Road
    City / Town / Township / Municipality
    Drop-Off Address: Caregiver Name: ______________________________________
    Phone No. ______________________
    ______________________________________________________________________________________________________
    Apt + House # or Lot/Conc.
    Street/Road
    City / Town / Township / Municipality
    HEALTH INFORMATION
    Medical Conditions (include information on assistive equipment or medication, if required):
    Does the student require Emergency Medication?
    Yes
    No
    If yes, please specify:_______________________________
    ADDITIONAL STUDENT INFORMATION
    (if required by the school)
    RELEASE FOR PUBLICATION OF STUDENT NAME, PHOTO AND SCHOOL-RELATED WORK
    I hereby give
    District School Board Ontario North East
    permission to:
    ?
    publish my image (photographs) taken of me with or without other students in newspapers and other media, Board
    pamphlets, District School Board Ontario North East website and other similar promotional materials;
    ?
    display my school-related work or comments on the District School Board Ontario North East website and other similar
    promotional materials; and
    ?
    share my school-related work only with Board employees for educational purposes.
    Yes
    No
    This permission remains in effect until the Parent/Guardian or adult Student (18 years and over) advises the
    school otherwise in writing.
    _
    Student Signature (if over 18 years)
    OR
    Parent/Guardian Signature
    Date

    Student Registration Form
    Page 4 of 4
    (please print)
    CANADA’S ANTI-SPAM LEGISLATION
    (To be completed if you provided an email address with your contact information)
    Canada’s Anti-Spam Legislation prohibits the sending of commercial electronic messages, including emails and other forms of
    digital messaging if the electronic message encourages participation in a commercial activity unless the sender has received the
    recipient’s consent prior to sending the message.
    DSB Ontario North East and your child’s school require your consent to send any electronic messages which promote,
    advertise or offer for sale anything including school pictures, field trips, yearbooks, books, uniforms, food programs,
    event tickets or entry fees, fundraising events or items, or similar events or offers to sell goods and services.
    You may withdraw your consent for receiving commercial electronic messages at any time by notifying the Principal of the
    school where you or your child attends in writing or by visiting our website
    www.dsb1.ca
    and using the “
    unsubscribe
    ” button.
    Please check ONE of the following:
    I wish to receive commercial electronic messages from my child’s school.
    I do NOT wish to receive commercial electronic messages from my child’s school.
    _
    __________________
    Student Signature (if over 18 years)
    OR
    Parent/Guardian Signature
    Date
    ACKNOWLEDGEMENT – Please Read and Sign
    Student personal information is collected during registration and while attending school pursuant to the Education Act and its
    regulations and within guidelines set out in the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and
    the Personal Health Information Protection Act (PHIPA). It will be used for planning and programming, school to home
    communications, and to establish the Ontario Student Record which contains information conducive to the improvement of
    instruction. Limited information may be disclosed beyond the board for purposes such as yearbooks and accident information to
    the board’s insurer.
    As students progress from elementary to secondary school, important information is shared which eases a student’s transition to
    secondary school. Sharing it also improves our ability to program effectively to the benefit of all students. Select student
    information will be shared at different times as required. This is authorized under the Education Act. Please note that all
    information used for the transition process is limited, secure and protected at all times.
    Although opportunities will be provided to update this information annually, parents/guardians are expected to advise
    the school of changes in address, custody, medical conditions, etc. as they occur.
    Questions about the information collected on this form should be directed to the principal of the school.
    Acknowledgement: I certify that the information given on this form is true and correct. I have read and
    understand that it is my responsibility to keep the school advised of any change in the above information
    as soon as possible. I also give my consent to forward any or all of this information to school board
    officials.
    ____________________________________
    _______________________________________
    ___________________
    Name of Parent/Guardian signing
    (please print)
    Signature of Parent/Guardian
    (or student if 18 or older)
    Date
    ____________________________________
    _______________________________________
    ___________________
    Name of School Staff Member signing
    Signature of School Staff Member
    Date
    H:A17: Registration Form
    (updated
    August 2016)

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