VSB Summer Learning Registration for Non-VSB Students

Page 1 of 1

	STUDENT INFORMATION

1.	Student Legal Last Name:* Please use the legal last name shows on your ID

2.	Legal First Name* Please use the legal names show on your ID

3.	Legal Middle Name Please use the legal names show on your ID. Leave this blank if there is no legal middle name.

4.	Usual Last Name*

5.	Usual First Name*

Gender*

	Female
	Male

7.	Date of Birth*
	dd/mm/yyyy

8.	Personal Education Number (PEN)* Enter the 9-digits number

9.	Citizenship*

10.	Is the student a Study Permit Holder?*
	Yes No

11.	if yes to the above question, what is the Study Permit expiry date? If no, skip to the next question.
	dd/mm/yyyy

12.

Indigenous Ancestry*

	Yes
	No

13.	Home Language*

14.	BC Personal Health Card No. Enter the 10-digits number

15.	Does the student have any Life-Threatening Medical Condition?*
	Yes No

16.	If yes to the above question, please specify the medical condition.

	STUDENT HOME ADDRESS AND PHONE NUMBER

17.	Apartment Number, if applicable

18.	Street Number and Street Name*

19.	City*

20.	Postal Code*

21.	Home Phone Number*

22.	Mailing Adress if different from the above Please leave this blank if mailing address is same as home address.

	PARENT/GUARDIAN INFORMATION Enter one parent/guardian who lives with the student

23.	Parent/Guardian Last Name*

24.	Parent/Guardian First Name*

25.	Relationship to Student*

26.	Parent/Guardian Primary Phone*

27.	Parent/Guardian Secondary Phone

28.	Parent/Guardian Email* Email address where confirmation will be sent to after the form is submitted.

	EMERGENCY CONTACT Enter one of the emergency contact who can pick up the student in case of emergency.

29.	Emergency Contact Last Name*

30.	Emergency Contact First Name*

31.	Emergency Contact Phone #1*

32.	Emergency Contact Phone #2

33.	Emergency Contact Relationship to Student*

	CURRENT SCHOOL INFORMATION

34.	Current School Name*

35.	Current School District* For example: Vancouver, Burnaby, Richmond, Surrey etc.

36.	Current Grade Level (2-digits for grade level, ie. KF, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12)*

37.	Does the student receive Education Assistant support during the regular school year?
	Yes No

38.	Does the student have an Individual Education Plan?
	Yes No

39.	Does the student currently have a Ministry of Education Special Education Designation?
	Yes No

	PARENT/GUARDIAN ACKNOWLEDGEMENT

41.

The information on this form is collected under the authority of the School Act, Section 13 and 79. The information provided will be used for educational programs and administrative purposes, and when required, may be provided to health services, social services or support services as outlined in Section 79(2) of the School Act. The information collected on this form will be protected consistent with the Freedom of Information and Protection of Privancy Act.

*

I certify that the above information is correct and valid as of this date. I understand that the provision of false information may lead to my child no longer being enrolled in the Vancouver School District Summer Learning Program.

42.	Date of Application*
	dd/mm/yyyy

Done