Renfrew County District School Board

VALOUR SECONDARY STUDENT REGISTRATION

Office Use Only / Year: (Circle One) / 1 / 2 / 3 / 4 / 5
School / Request for OSR Date:
Diploma - Working towards
OSSD (under OSS) (1999) / OSSC (B) / Cert of Accomp (A) / OSSD (under OSIS) (1989) / SSGD
Academic Transcript of Marks / 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
Cohort – Sch yr first entered gr 9 in Ont / OEN Verified
First Entry Dt to Secondary in Ont / Student Activity Registration Fee
Cross Boundary / Start Date
Proof of Residence (ie: lease or sales agreement, phone bill, driver’s license)

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

Date of Birth: (YYYY/MMM/DD) ______Siblings: ______

Home Address: ______Apt. #: _____ Unit # _____ Post Office Box: ______Street Number/Street Name

______911 Number:______City/Township Postal Code

Home Phone Number: ______Listed: Unlisted:

Mailing Address:______Apt. #: _____ Unit # _____

(If different from above) Street Number/Street Name

______

City/Township Postal Code

Last School Attended: ______Last Grade Attended: ______

Address: ______

Street Number/Name City Province/State Country

Language of Instruction: ______Departure Date: ______

Reason for Transfer: ______

Have you ever been enrolled in a Renfrew County D.S.B. school? Yes No

For Out-of-Province students only:

If you ever attended a school in Ontario, Name the school: ______

Health Card Number: ______Version: ______Immunization Record Provided: Yes No

Medical Peril: Yes No Medical Alert Information/Disability/Allergies: ______

______

Doctor’s Name: ______Telephone Number: ______Ext. ______

Student Identification through IPRC: Yes No Student has an IEP: Yes No

French Exempt: Yes No French Immersion Program: Yes No

Custody Information:

Legal Custody Mother & 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______Apt. # _____ Unit # _____

Street Number/Street Name City/Township Postal Code

Home Phone: ______Cell: ______e-mail: ______

Business Phone: ______Ext. ______Employer Name: ______

Living With: Mother & Father Mother Only Father Only Other Specify: ______

Contact Priority: (circle one each) Emergency: 1 2 3 4 School Closure: 1 2 3 4

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______Apt. # _____ Unit # _____

Street Number/Street Name City/Township Postal Code

Home Phone: ______Cell: ______e-mail: ______

Business Phone: ______Ext. ______Employer Name: ______

Living With: Mother & Father Mother Only Father Only Other Specify: ______

Contact Priority: (circle one each) Emergency: 1 2 3 4 School Closure: 1 2 3 4

Has access to school records: Yes No

Emergency Contact Information (other than guardians)

Title: ______First Name: ______Surname: ______

Relationship to student: ______Gender: Female Male

Home Phone: ______Cell: ______

Emergency Contact Information (other than guardians)

Title: ______First Name: ______Surname: ______

Relationship to student: ______Gender: Female Male

Home Phone: ______Cell: ______

Transportation: Bus Walk Auto Other

Signature: ______Date: ______