FORT MCMURRAY PUBLIC SCHOOLS Early Childhood Registration Form Mission Statement Fort McMurray Public School District Js A Learning Community Dedicated to Educating All Students For Personal Excellence. Date of Registration: CEcop (Early Childhood Development Program). Scho CiprescHoot: Preference: Clam (Cipm Child's Name: © (Male [Female Section 23 de la Charte Canadienne des (ives [No Does this child have the right to receive his/her education in French aécording to Section 23 of the Canadian Charter of Rights and Freedoms? (If so, you should complete @ declaration to that effect) [-] Yes: [-] No FOR OFFICE USE ONL) Alberta Learning No. son, District Revised 5/12/20104. CHILD'S INFORMATION ‘Wille the child's legal sumame (last name) and first name below. These are the names on the child's birth certificate or adoption papers, Child's Legal Sumame’ Child's Legal First Name: Child's Legal Middle Name(s): Date of Birth t : ‘School's verification of birth date: O) Birth Certificate 1 Passport OD other “Day Wort Year Copyreceived for student flo [1] izenship of child: Oicanadian Citizen C] Landed immigrant [] Student Visa [1 Child of a temporary resident Expiry Date: Copy received for student ia] First language spoken in the hom ‘Second language spoken in the home: English T French Other 0 English O French 1 Other Ifyou wish to declare that you have Aboriginal heritage, please specity: ‘Status Indian/First Nations ‘Non-Status Indian/First Nations Métis Inuit ‘No Aboriginal Heritage Treaty Number: Band Name: Alberta Learning is collecting this personal information pursuant fo section 33 (c)) of the FOIP Act as the information relates directly to and is necessary to meet its mandate and responsibities to measure system effectiveness over time and develop polices, programs and ‘services to improve Aboriginal learner success. For further informaton or if you have questions regarding the collection activity, please contact the office of the director, Aboriginal Policy, Policy Sector, Information and Sirategic Services Division, Alberta Learning, 10165 102 Street, Edmonton AB TSJ 4L8. (780) 427-8501 List all siblings, whether of school age or not: Name: Date of Male Name: Date of Bith Male Name: Date of Birth Male _ CHILD HAS BEEN ENROLLED IN A SPECIAL PROGRAM: IPP WRITTEN MEDICAL INFORMATION Child's Medical Information. This information is often helpful for school staff. Are there any serious medical conditions about which you wish the school to be aware: []Yes [] No If yes, please list below: Medical notes CHILD'S RESIDENCE: Child lives with: (check one) [Lieoth Parents [] 1" Parent [1] 2™Parent other (piease specify)Custody: In rare instances a child may be designated as ‘Protected’ if a court has issued a restraining order under the Child Welfare Act, the Domestic Relations Act, the Divorce Act, or the Young Offenders Act. Please indicate if the school administration should be aware of any such Court Order for the protection of your child. [] Yes [] No (if*yes” please make arrangements to discuss this situation with the school administration. Legal documentation will be required.) PARENT (OR LEGAL GUARDIAN) RESIDENCY INFORMATION I thre re two parents or legal guardians, tis important ofilin both sections 2 and 3 whether or not he parents o legal guarclans a ving together. (a iegl guardian” i @ person pointe bythe cour as te guarlan. Documentaton i required). FIRST PARENT OR LEGAL GUARDIAN Surname! pe _ Me. Ms First Name! _ ee _ Relationship to Student: (Mother [] Father [) Legal Guardian [7] Other Piease specify Address: __ - : City: Postal Code: Home phone: Business phone: Cell phone: - Pager: Email Address: (lease print) 3. SECOND PARENT OR LEGAL GUARDIAN Surname’ Me Mes. First Name: : Ms. ee Relationship to Student: Cimother (Father [] Legal Guardian] Other Please specity_ a ‘Address: - City = Postal Code’ _ Home phone: _ Business phone: Cell phone: Pager: Email Address: (please print) 4._EMERGENCY CONTACT Tin "emergency contact person" Is someone other than the child's parent or guardian. Mr rs. Ms. ete ‘Surname: First Name: Address: OO Home phone: Relationship to Student Business phone: Call phone:5. FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT (FOIPP) ‘The information collected on this form as part of the school registration process Is personal Information as referred ta in the FOIP ‘Act. This personal information is collected pursuant to the provisions of the Schoo! Act and its regulations (e.g. for the establishment of a student record, determination of residency) and pursuant to section 33(c) of the FOIP Act as the collection is related directly to land is necessary to’2 school board's obligation to provide students with an education program that meets thelr needs and to provide 8 safe and secure school environment (e.9. progrem placement, determination of eligibility andor sultabllty for provincial or federal funding, contact and health related information in the event of problems or emergencies). Personal information may also be Provided to the Minister of Education for the purpose of carrying out programs, activites, or policies under his administration (e.g, research, statistical analysis) | give Fort McMurray Public Schools/District permission for: Yes No my child to accompany his/her class on school sponsored field trips. my child’s work to be displayed within the school, at community and public events and competitions, my child's image to appear in yearbooks, class albums, on'ID cards and schoo! displays. my child's image to appear on schoo! websites, public displays and in the media. my child’s name to be released with respect to special recognition to the school district, government or media officials. my child’s name to be included in the list of names, phone numbers, class lists for distribution to supervisors, parent association, volunteers, school council and school newsletters. my child’s speech, language, fine motor, gross motor and general development to be assessed by qualified personnel. oOooo000o00 ooo0000o 6. SCREENING & ASSESSMENT INFORMATION Yes No TF 1 Are you aware of or do you suspect that your child may have a developmental (speech, language, physical, social, intellectual, emotional) delay? If so, please describe. Cae Has your child been assessed by health authority personnel or other agency for developmental delays, disabilities, etc.? I so, please provide details or attach a report if avalable. CD _ Ss your child toitet-trained? 7, DECLARATION BY PARENT OR LEGAL GUARDIAN | hereby certify the foregoing information to be true, correct and complete. Date Signature OPTIONAL INFORMATION Religious denomination: