School District 70 (Alberni)
APPLICATION FOR ALTERNATIVE EDUCATION
Please use a pen when completing this form. Return to: VAST Education Centre, Unit #202-4152 Redford Street, Port Alberni, B.C. V9Y 3R5 Phone: (250)723-3744
A.PERSONAL INFORMATION
NAME: ______Program Requested:
(First Name)(Middle Names)(Last Name)
Age: ______Date of Birth: ______Last Grade Completed: ______Phone: ______
Address: ______Postal Code: ______
Student Email Address: ______Parent/Guardian Email Address: ______
B.FAMILY BACKGROUND
Mother/Guardian: ______Home Phone: ______
Address: ______Cell or Work Phone: ______
Father/Guardian: ______Home Phone: ______
Address: ______Cell or Work Phone: ______
Siblings: NameBrother/SisterAge
______
______
Describe your current living situation (eg. who you live with, parents/relatives/friends/foster home, on your own, etc.):
C.SCHOOL BACKGROUND
Last school attended: ______When: ______
Are you in school now? ______If no, reason for leaving: ______
Who can VAST contact at your last school for information? ______
- REASON FOR APPLYING
Why are you applying for alternative education? ______
What grade are you enrolling in and what courses do you plan to take?
______
E.HEALTH
Do you have any health issues? ______
Do you take any medications? (please list) ______
2
F.FUTURE GOALS
What job/career do you hope to have when you have completed your education? ______
G.INVOLVMENT WITH COMMUNITY SERVICES(This does not apply to me □)
Do you have contact with the Ministry of Children and Family Development? ______and/or Usma Nuu-Chah-Nulth Child and Family Services?______
Do you have a social worker? yes no IfYes,name: ______Phone No.: ______
Do you have a family support worker? yes no If Yes, name: ______Phone No.: ______
What other community support agencies do you have contact with:
probation officer family counsellor drug & alcohol counsellor Other None
Names of community support agency workers: ______
H.ABORIGINAL SELF IDENTIFICATION(This does not apply to me □)
Are you of aboriginal ancestry? ______What is the name of your First Nations band? ______
What is your status number? ______
I.FINAL COMMENTS
Tell us more about yourself, your education and your life plans:
______
______
For Office Use Only:Program Placement: ______Date: ______
Other Recommendations: ______
Applicant’s SignatureDate
VAST applications
School District 70 (Alberni)
APPLICATION FOR ALTERNATIVE EDUCATION
Please use a pen when completing this form. Return to: VAST Education Centre, Unit #202-4152 Redford Street, Port Alberni, B.C. V9Y 3R5 Phone: (250)723-3744
Student’s Name: ______Email: ______Age: ______D.O.B. ______Mother/Guardian: ______Email: ______Home Phone: ______
Address: ______Work #: ______Fax #: ______
Father/Guardian: ______Email: ______Home Phone: ______
Address: ______Work #: ______Fax #: ______
Emergency Contacts:NamePhone Number
Absence Contact______
Emergency Contact______
Family Doctor______
Why is your son or daughter applying to come to VAST?
______
Please describe how we can best assist your son or daughter to be successful at VAST:
______
Is there anything we need to know about your son or daughter that would help us to provide the best educational program possible for your son or daughter (physical, psychological or academic challenges)?
______
Please describe any school supports or community agencies that have been involved with your son or daughter in the past.
______
I hereby verify the above to be correct and fully support this application: ______
Parent/Guardian Signature Date
VAST applications