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0% found this document useful (0 votes)
13 views3 pages

Original File From Success

Uploaded by

obehiobehi77
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ELEMENTARY STUDENT REGISTRATION FORM

349 Erie Avenue, Brantford, N3T 5V3 519-756-6301 1-888-548-8878 www.granderie.ca

Notice to Parent/Guardjan
Thank you for your interest in an elementary education with the Grand Erie District School Board. To register a student, the
parent/guardjan is required to provide information tb the school by completing this Registration Form. Ensure that you complete all
sections and provide the school with all of the original documéntation requlred, as noted on the form.

Notice of Collection and Use of Personal Information


Information on this Registration Form is collected under the legal authority of the Education Act and in accordance with the
Municipof Freedom of Information and Protection of Privacy Act [MFIPPA]. It will be used to establish the Ontario Student Record
[OSR], and for student and education related purposes, such as registration, administration, communication, data reporting, and
Student Transportation Services Brant Haldimand Norfolk. Student information such as name, D.O.B. and contact information is
released to the Regional Health Units in accordance with the Health Protection and Promotions Act and the Immunization of School
Pupils Act.
Questions or concerns should be directed to the principal of this school or einail [email protected]
SCHOOL START DATE:
"fÜBENTtiNiOÅMATlONSUMMARY

LEGAL LAST NAME: TITUS- EBHODAGHE LEGAL FIRST NAME: SUCCESS

PREFERRED (usual) NAME: SUCCESS TITUS LEGAL MIDDLE NAME(S): ONOSASELE

BIRTH DATE - MM/DD/YYYY GENDER LIVES WITH: Is there a court order regarding custody?
Female Mother Legal Guardian No if es rovide
documentation
ADDRESS HOME PHONE NUMBER
6478253420
Apt/Urdt: UPPER House: 66Full Street Name: Marlborough street Citynown: Brantfort postal Code: N3T 2S3

Please help us to understand special living arrangements (e.g., student does not live with a parent) and/or custody orders by provldlng details here:

LEGACPARENT.S and GUARDIANS


NAME of PARENT/.GUARDIAN: TITUS-EBHODAGHE STELLA EMEM i)HdNES (indicate Home, Work or tell) Home

MÅIN.* 6478253420 o
APDRESS (if different from stÜdent)
2ND.
3RD; o
Apt/Unit House Full Street Name
E-MAIL ADDRESS (only; if y6u consent to ieceiVe Emails fio}fi the
[email protected]

own Code
NOTES— PARENT/GUARDIAN ifVou Wish to provide information that will help us to understand the student's family context such as stepparent, common-law spouse

NAME of LEGAL PARENT/GUARDIAN: PHONES (indicate Home, work or cell) HWc

MAIN: ooo
ADDRESS (if different from student) 2ND. ooo

A t/Ünit House: Fun Street Name: 3RD: ooo

E-MAIL' ADDRESS (only if you consent to recelve emails from the schoo}):

own Postal Code


NOTES-- PARENT/GUARDIAN #2 If you wish to provide Information that will help us to understand the student's family contpxt such as stepparent. common-law spouse

NAMES OF SIBLINGS ATTENDING SCHOOLS IN GRAND ERIE who live at the same address as the student

SCHOOL HISTORY
DETAILS OF PREVIOUS SCHOOLING OEN (Ontario Education Number) if known

Private Out of Province/Country


LAST SCHOOL ATTENDED: New life baptist school, Lagos, Nigeria/ Fajip Private Schools LOCATION

LANGUAGE OF LAST SCHOOLATTENDED


English DATE OF ENTRY TO RRST ELEMENTARY SCHOOL -09/17/2018

Has student attended a Grand Erie school before? No


Is student currently expelled from previous school?
No
Was Special Education Programming accessed at the previous schoof? Not If yes, was there an Grade student entering:
Individual Education Plan (IEP)? Not Sure Sure Grade 6

Study Permit/Visitor RecordO

COUNTRY OF CITIZENSHIP NIGERIA DATE OF ENTRY TO CANADA (If applicable) - 2024/09/04

COUNTRY/PROVINCE OF BIRTH PREMOUS PROVINCE/COUNTRY OF RESDENCE NIGERIA


LAGOS, NIGERIA
FIRST IANGUAGE SPOKEN: ENGLISH IANGUAGE CURRENTLY SPOKEN AT HOME:
ENGLISH

EMERGENCY CONTACT/MÉDitÄL iNÉöäMÄttotiJ Méd Form O Mé_d. F.ptm O)


Does student have a condition that coutd lead to anaphylactic shock? YesO NOO if yes, please provide medical information/documentation
Please provide medical informatlon/documentation that the school needs to be aware of:

EMERGENCY CONTACT (other than parent/guardian) Can ptck up student RELATIONSHIP PHONE(S): 6478253245
Yes
EMERGENCY CONTACT (other than parent/guardian) Can pick up student RELATIONSHIP PHONE(S): 6478253683

Yes
EMERGENCY CONTACT (other than parent/guardfan) Can plck up student RELATIONSHIP PHONE(S): +1 (226) 966-6397

Yes
have obtained the consent of the person(s) Eisted above to have their name and telephone number used for emergency purposes Yes

STUDENT WALKS
ÄÖDltTÖNÄL iNÉöÄMÄilötv
SELF-IDENTIFICATION (if applicable) this is voluntary/optlonal First STUDENT LIVES ON:
NationsO MétisO Inuit Dix Nations of the Grand River OMississaugas of the Credit
LUNCH BREAKS It importantthatwe know_where your chiidren are. Students who eat atschool must previde a signed, dated note with your consent to leave
school property during breaks.
Please Indicate whether your child: WILL be eating at school

PERMISSION ACKNOWLEDGEMENTS AND RELEASE OF INFORMATION


Media Consent: I give permission for my child's personal information (e.g., picture, video, name, school work). to appear
on school websites, on the board's social media outlets such as its YouTube channel, Facebook, Twifter account and in
school-related stories in the newspaper, school or board brochures, student produced online newspapers and reports
on websites. I understand that by consenting, my child's photo, video, school work, and/or name could be used in a way
that makes it accessible to the public. Yes
Consent to Receive School Emails: Canada has implemented Anti-Spam legislation which requires us to have your
consent to send you emails with content related to "commercial activity" such as information on yearbook sales, school
fundraisers, field trips, student pictures, books, dance tickets, etc. If you wish to receive these emails, please indicate
that here. You may withdraw your consent at any time by contacting the school. Yes
I verify that the information provided on this form is true and correct. I understand that it is my responsibility to inform
the school immediately of any changes to the information contained on this form.
SIGNATURE OF PARENT/GUARDIAN DATE

FitedinOSR Retention: E + 10 years (E — retiled student) Rev; Januay 2020

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