OSR Ordered_________________
OEN #:____________________
Gender: _______(M/F)
Birthdate: ________________________
(D/M/Y)
PROPERTY ADDRESS
R R No: _______
Town: _________________________
ALTERNATE ADDRESS (only if student will be taking a bus from/to other than property address above every day.)
Contact Name: _____________________________
R R No: _______
Apt # ___________________
Municipality: ____________________________
IMMIGRATION INFORMATION
Immigration Status: _________________________
Fee Paying Student: ______ (Y/N)
MEDICAL INFORMATION
OHIP No: _______________________________
Dentists Name:___________________________
Allergies: _____________________________________________________________________
Health Conditions:______________________________________________________________
Medications: _____________________________________________________________________________________________________
Other Information:_________________________________________________________________________________________________
PARENT/GUARDIAN INFORMATION
Who Has Legal Custody: ___________________
(documentation required)
2. Relationship _________________________
_________________________________
____________________________________
Relationship: _______________________
Relationship: _________________________
Address: __________________________
Address: ____________________________
__________________________________
____________________________________
___ Metis
___Inuit
SIBLING INFORMATION
Name
Relationship
Age
School
Grade
Gender
1.
_____________________ _______________
_____
____________________________
______
______
2.
_____________________ _______________
_____
____________________________
______
______
3.
_____________________ _______________
_____
____________________________
______
______
I verify that the information on this form is true and correct. I understand that it is my responsibility to keep the school advised of any change
in the above information as soon as possible. I also give consent to forward any or all of this information to School Board Officials or the
School Nurse. The information collected in this document is collected under the authorities of the Education Act of the Province of Ontario.
In the event of an emergency, I authorize the school staff to call a physician, preferably, but not necessarily our family doctor, and to send my
child to the hospital.
I certify that I have been informed that an Ontario Student Record is on file at the school and that I have access to the information therein.
_____________________________________________
Parent/Guardian Signature
__________________________________________
Date