Application Form

Application for enrolment starting:     Month January February March April May June July August September October November December      Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year: 2006 2007 2008 2009 2010 PERSONAL INFORMATION: Student's Usual Names Student Surname:.......................... First Name:..................................... Middle Name:................................. First Name Normally Used:............. Gender:......................... Male Female   Birth date:  Month........................... January February March April May June July August September October November December Day:................................... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year:.............. 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006     Registering for Grade:.................... K 1 2 3 4 5 6 7 8 9 10 11 12 Birth Certificate No:........................ Birth Place:.................................... Citizenship:.................................... Foreign Student:............................ Yes No Religion:........................................ Registered Parish:......................... Language spoken at home:........... Baptism:.......................... Yes No Reconciliation:.......... Yes No First Communion:............ Yes No Confirmation:............ Yes No Aboriginal Ancestry:...................... Status NON-Status Metis Other No Yes Band Name and No: FAMILY INFORMATION: Mailing Names: ......Initial.... Surname: Mailing Address:.......................... House Address: (If different)......... City:............................................. Postal Code:.......... Home Phone:........ Email: Parent (Father/Caregiver):........... Resident in Home:........................ Yes No Father's Employer:....................... Father's Work Phone:.................. Father's Occupation:................... Parent (Mother/Caregiver):.......... Resident in Home:....................... Yes No Mother's Employer:..................... Mother's Work Phone:................. Mother's Occupation:.................. Emergency Contact:................... Emergency Phone:..................... Daycare/Babysitter:..................... Babysitter Phone:........................ Names and birthdays of brothers and sisters: Did you or your spouse formerly attend St. Ann's Academy?.. Yes No If yes, please complete the following: Father's last year attended:.......... Mother's last year attended:......... Mother's Maiden Name:................ Other family members who attended: EDUCATIONAL INFORMATION: Former School:............................ Address:....................................... City:............................................. Province:...................................... Postal Code:................................. Has this child received Special Education Programming ? No Yes Has this child received Learning Assistance ? No Yes LEGAL INFORMATION: Student's Legal Name: (If different from usual name) Last:.............................................. Middle:.......................................... First:.............................................. Legal Father's Name: (If different from usual name) Last:.............................................. Middle:.......................................... First:.............................................. Legal Mother's Name: (If different from usual name) Last:.............................................. Middle:.......................................... First:.............................................. Is there a court order in effect ? No Yes If "Yes" please give details concerning custody and guardianship: Note: Copy of an up-to-date court order must be on file with the school MEDICAL INFORMATION: Immunization Form Completed ? No Yes Care Card Number:........................ Doctor's Name:............................... Doctor's Phone #:........................... Medical Alert ?.............................. No Yes Physical Limitations: Is this child currently on any medication ? No Yes If "Yes" Please give description: To be completed by the Parent/Guardian: Why do I want my child/guardian to come to St. Ann's Academy? DECLARATION: I GIVE PERMISSION FOR THE TRANSFER OF ALL INFORMATION AND DOCUMENTATION PERTAINING TO MY CHILD AS NAMED ABOVE IF TRANSFERRING FROM A BC PUBLIC SCHOOL, OR A SCHOOL OUTSIDE BC. I GIVE MY CONSENT FOR THE RELEASE OF MY NAME, PHONE NUMBER AND ADDRESS FOR SCHOOL COMMUNICATION PURPOSES, SUCH AS PARENTS AUXILIARY AND CLASSROOM PHONING COMMITTEE, ETC. I GIVE MY CONSENT FOR THE PUBLICATION OF MY CHILD'S NAME, PHOTOGRAPH, AND COMMENTS FOR SCHOOL PURPOSES IN THE SCHOOL YEARBOOK, NEWSLETTER, AND ON OCCASION IN THE NEWS MEDIA. I AGREE TO THESE CONDITIONS Parent/Guardian Date: