Renfrew County District School Board

Office Use Only / Year (Circle One) / JK / SK / 01 / 02 / 03 / 04 / 05 / 06 / 07 / 08
School: / Valour Jk-12 School / English / Immersion
Class / Request for OSR Date
Application for Direction of School Support / Identified as an Exceptional Student
Proof of birth / Immunization Certificate/Letter of Refusal
Citizenship/Immigration Verification / Internet Agreement
Custody Order (if applicable) / Medication Forms
RCDSB Student ID#: / Most Recent Report Card
Cross Boundary / OEN Verified
First Entry Dt to Elementary in Ont / Start Date

PLEASE PRINT LEGIBLY

Student’s Legal Name (as on birth certificate) / Student’s Preferred Name / Same as Legal Name
Surname: / Surname:
First Name: / First Name:
Middle Name(s): / Middle Name(s):
Gender: / Female / Male / Birthdate: (ie: May 1, 1990)
If student is entering from outside Ontario, please indicate province or country:
Previous school board: / Last attendance day:
Previous school: / Previous Grade: / Phone:
Address:
Health Card Number:
Doctor: / First Name: / Surname: / Phone:
Medical Alerts/Disabilities:
Sibling(s) at this school:
If student is born outside Ontario: / Province:
Birth Country: / Arrival date in Canada:
Status in Canada: / Canadian Citizen / Permanent Resident / Other Visa
Refugee / Landed Immigrant / Visa Student
Country of last residence: / Country of Citizenship
Aboriginal Ancestry: / Do you wish to voluntarily identify this student as being a person of Aboriginal Ancestry? / Yes / No
If yes, is he / she: / First Nation on Reserve / Inuit
First Nation off Reserve / Métis
Student’s Address (civic address must be recorded)
City:
Number: / Street: / Apt:
Group Box: / Box: / R.R.:
Township: / Prov: / Postal Code:
Telephone: / e-mail:
Custody Information
Who has legal custody? / Mother and Father / Mother Only / Father Only / Other
Are there any special arrangements pertaining to access/visitation? / Yes / No
If yes, please specify and provide custody order.
First Guardian Contact Information
Title: / First Name: / Surname:
Relationship to student: / Gender: / Female / Male
Address: / Same as student or:
Home Phone: / Cell: / Pager:
e-mail: / Other Phone (specify type):
Business Phone: / Employer Name:
Contact Priority: (circle one each) / Emergency: / 1 / 2 / 3 / 4 / 5 / School Closure: / 1 / 2 / 3 / 4 / 5
Speaks English: / Yes / No / Has access to school records: / Yes / No
Second Guardian Contact Information
Title: / First Name: / Surname:
Relationship to student: / Gender: / Female / Male
Address: / Same as student or:
Home Phone: / Cell: / Pager:
e-mail: / Other Phone (specify type):
Business Phone: / Employer Name:
Contact Priority: (circle one each) / Emergency: / 1 / 2 / 3 / 4 / 5 / School Closure: / 1 / 2 / 3 / 4 / 5
Speaks English: / Yes / No / Has access to school records: / Yes / No
Sitter Information (other than guardians) / Student does not go to a babysitter
Title: / First Name: / Surname:
Relationship to student: / Gender: / Female / Male
Address: / Same as student or:
Home Phone: / Cell: / Pager:
e-mail: / Other Phone (specify type):
Business Phone: / Employer Name:
Contact Priority: (circle one each) / Emergency: / 1 / 2 / 3 / 4 / 5 / School Closure: / 1 / 2 / 3 / 4 / 5
Speaks English: / Yes / No
Emergency Contact Information (other than guardians or sitter)
Title: / First Name: / Surname:
Relationship to student: / Gender: / Female / Male
Address: / Same as student or:
Home Phone: / Cell: / Pager:
e-mail: / Other Phone (specify type):
Business Phone: / Employer Name:
Contact Priority: (circle one each) / Emergency: / 1 / 2 / 3 / 4 / 5 / School Closure: / 1 / 2 / 3 / 4 / 5
Speaks English: / Yes / No
Emergency Contact Information (other than guardians or sitter)
Title: / First Name: / Surname:
Relationship to student: / Gender: / Female / Male
Address: / Same as student or:
Home Phone: / Cell: / Pager:
e-mail: / Other Phone (specify type):
Business Phone: / Employer Name:
Contact Priority: (circle one each) / Emergency: / 1 / 2 / 3 / 4 / 5 / School Closure: / 1 / 2 / 3 / 4 / 5
Speaks English: / Yes / No
Transportation / Bus/Taxi / Walk/Own Transportation / Other
Morning Pick Up: / Home / Sitter / Afternoon Drop Off: / Home / Sitter
Signature: / Date:

Personal information on this form is collected under the authority of the Education Act. The personal information collected will be used for education, administration, and statistical purposes of the Board and/or Ministries and Agencies of the Government of Ontario and the Government of Canada. Questions about this collection of personal information should be directed to the Freedom of Information Co-ordinator, 1270 Pembroke Street West, Pembroke, Ontario K8A 4G4 613-735-0151.

l:\progdoc\trillium\forms\rcdsb elementary registration form.docRevised January 2010