Student Transfer Form

WRDSB to WRDSB ONLY - Confidential

FS-21-HT
AP 4270
STUDENT INFORMATION – PLEASE PRINT

Legal Surname: Legal First Name:

Preferred Surname: Preferred First Name:
Legal Middle Name: Gender: □ Male □ Female □ Not Disclosed □ Self-Identified
Home Phone: □ Unlisted If Self-Identified: □ Two-Spirit □ Genderqueer
□ Gender Fluid □ Gender Nonconforming □ Intersex
Date of Birth (year-month-day): □ Non-Binary □ Trans □ Other
Please list student’s siblings in this school:
Is the student currently expelled from any school or school board? □ Yes □ No
STUDENT ADDRESS INFORMATION

Home Address:
Number Street Apt #

City / Town / Village / Municipality Province Postal Code

Mailing Address: Same as home address? □ Yes □ No If NO, please complete below

Number Street City / Town / Village / Municipality Province Postal Code

PREVIOUS SCHOOL INFORMATION

Name of Previous School:
□ English Program □ French Immersion Program Grade at previous school:
Last Date of Attendance: Reason for Transfer:

STUDENT LANGUAGE, CITIZENSHIP AND IMMIGRATION INFORMATION

Country of Birth: Citizenship:

Date Arrived in Canada:
Does the student have a current Letter of Admission (if applicable)? Yes □ No □
First Language: Language Spoken at Home:

STUDENT MEDICAL INFORMATION

(If this section is applicable to the student, there may be additional forms to be completed)
Allergies or Health Concerns:

Are any of the noted health concerns life threatening? □ Yes □ No Does the student require an epi-pen? □ Yes □ No

SPECIAL EDUCATION / IEP/ IPRC / ESL / ELD INFORMATION

Does your child receive any special education assistance (elementary or secondary)? □ Yes □ No
If YES, please provide details:

Has your child previously received English as a Second Language (ESL) or English Literacy Development (ELD) assistance? □ Yes □ No
If YES, please provide details:
January 2021 AP 4270 FS-21-HT
TRANSPORTATION ARRANGEMENTS FOR ELIGIBLE STUDENTS
STSWR determines transportation eligibility. To determine if a student is eligible, visit Bus Planner (https://bpweb.stswr.ca/). If a
student is eligible for board-funded transportation, indicate where the student will be picked up and dropped off:
□ Picked up at Home □ Dropped off at Home □ Picked up at Caregiver □ Dropped off at Caregiver □ Special Education Eligible
Pick up Address:
Number Street City / Town / Village / Municipality Province Postal Code

Drop off Address:

Number Street City / Town / Village / Municipality Province Postal Code

PARENT / LEGAL GUARDIAN / EMERGENCY CONTACT INFORMATION

Living With
□ Both Parents □ Mother Only □ Father Only □ Legal Guardian □ C.A.S/F&CS □ Other:
Custody
□ Both Parents □ Mother Only □ Father Only □ Joint □ Legal Guardian □ C.A.S/F&CS □ Other:
If joint custody checked, please indicate schedule: □ Weekly □ Bi-Weekly □ Monthly □ Other:
Provide alternate address for joint custody:
Is there a legal document that sets out custody and access to the student?
□ No □ Yes (please provide school with copy of legal document for OSR)
PARENT / LEGAL GUARDIAN / EMERGENCY CONTACT INFORMATION
Contact 1 Name: _____ □ Male □ Female □ Undisclosed
Title (Mr., Mrs., Dr., etc.) Last Name First Name

Relationship to Student: Employer (optional):

Check all applicable boxes Has access to Student: □ Yes □ No □ Legal Guardian □ Receives Mail
□ Has Custody □ Has Access to Records
Emergency/Attendance Contact Priority: □ First □ Second □ Third □ Lives with Student □ Speaks English
Home Number: Priority: (1-3)
Business Number: Priority: (1-3)
Cell Number: Priority: (1-3) Email Address:
Address: □ Same as Student’s Home Address □ Address Below:

Number Street City / Town / Village / Municipality Province Postal Code

Contact 2 Name: □ Male □ Female □ Undisclosed

Title (Mr., Mrs., Dr., etc.) Last Name First Name

Relationship to Student: Employer (optional):

Check all applicable boxes Has access to Student: □ Yes □ No □ Legal Guardian □ Receives Mail
□ Has Custody □ Has Access to Records
Emergency/Attendance Contact Priority: □ First □ Second □ Third □ Lives with Student □ Speaks English
Home Number: Priority: (1-3)
Business Number: Priority: (1-3)
Cell Number: Priority: (1-3) Email Address:
Address: □ Same as Student’s Home Address □ Address Below:

Number Street City / Town / Village / Municipality Province Postal Code

Information on this Registration Form is collected under the legal authority of the Education Act and its regulations, and in accordance with the Municipal Freedom of Information and Protection of Privacy
Act. Information collected on this form will be used to establish the Ontario Student Record (OSR) and for other student and educational related purposes, such as registration, administrative,
communication, data reporting and transportation. The information may also be retained independently of the OSR for Ministry of Education reporting purposes. Questions or concerns about the collection
of data on this form should be directed to the Principal of the school or the Freedom of Information, Privacy and Records Information Management Officer, Waterloo Region District School Board.

PARENT/GUARDIAN/STUDENT (over 18) ACKNOWLEDGEMENT

I certify that the information that I have provided on this form is accurate. I understand that copies of custody documentation, if
applicable, will be included in the Ontario Student Record (OSR).

Parent/Guardian/Student (over 18) Full Name Signature Date

January 2021 AP 4270 FS-21-HT
 For School Use ONLY

SCHOOL CHECKLIST FOR STUDENT TRANSFER FROM WRDSB SCHOOL

Legal Last Name WRDSB Student #
Legal First Name OEN #
Entry Date Entry Type Grade Class/Homeform

Complete this section if the student has become a Permanent Resident or Canadian Citizen:
 Confirmation of Permanent Residence Date became a P.R.:
 Permanent Resident Card (see back of card)
 Canadian Citizenship Documentation Date became a Citizen:

Proof of Address/Residence in Waterloo Region

We can not accept Driver’s License as Proof of Address
 Government Issued Forms  Purchase/Lease Agreement
 Utility Bill  Tax bill
 Bank Statement  Property Insurance Bill

Proof of Custody (where applicable)

 Living with custodial parent(s)  Guardianship Agreement
 Custodial Court Order

I certify that the information contained on this form is accurate and that I have examined and verified the applicable information as
indicated.

Certified by Principal or designate:

Print name Signature

Position Date
This form and the information contained within it will be maintained in the Ontario Student Record.

Retention: E, plus 5 – file in OSR

January 2021 AP 4270 FS-21-HT