Thames Valley District School Board

____________________________________________________________

Date

Student Registration Form ____________________________________________________________

Enrollment School

Student Information
Legal First Name _____________________________ Preferred First Name __________________________

Legal Middle Name(s) _________________________ Preferred Last Name __________________________

Legal Last Name _____________________________ Ontario Education Number (OEN) ________________

Language First Spoken ________________________ Date of Birth (YYYY-MM-DD) ________-_____-_____

Main Language at Home _______________________ Gender ☐Female ☐Male ☐Non-Binary ☐__________

Indigenous Self-Identification ☐ First Nation ☐ Métis ☐ Inuit Other Details: __________________________

Student Address and Contact

________ ___________ ____________________________________ Main Phone #__________________
Apt # Street # Street Name

____________________________ ______________ Lives With __________________________________

City/Town/Municipality Postal Code

Previous School / Program Information

Name of School _________________________________ City/Province/Country ______________________

Name of Board __________________________________ Language of Instruction _____________________

Last Grade Attended ______________ Last Date Attended ________-_____-_____ ☐ ESL ☐ IEP ☐ IPRC

☐ Regular Program ☐ Specialized Program Describe ___________________________________________

Citizenship
Residency Status ____________________________ Country of Citizenship ___________________________

Country of Birth _____________________________ Country of Last Residence _______________________

Province __________________ Date student entered Canada for the first time to live ________-_____-_____

Student Health and Medical Alert Information

Allergies: _______________________________________________ ☐ Life Threatening ☐ Requires EpiPen

Description: ______________________________________________________________________________

Prevalent Medical Condition(s) ☐ Anaphylaxis ☐ Asthma ☐ Diabetes ☐ Epilepsy ☐ Other: _____________

Description: ______________________________________________________________________________

______________________________________________________________________________
Has the student previously had a concussion? ☐ Yes ☐ No They have a Medical Alert Bracelet ☐ Yes ☐ No
If student has any prevalent medical conditions, please complete the appropriate forms through the
parent portal or at the school; Individual Plan of Care (IPOC); Authorization for Administration of Daily
Prescription Medication; and/or Authorization for Administration of PRN Prescription Medication.
 Custody
Legal Guardian(s) ☐ Both Parents ☐ Mother Only ☐ Father Only ☐ Guardian: _______________ ☐ CAS

Custody Agreement ☐ Both Parents ☐ Shared ☐ Joint ☐ Mother Only ☐ Father Only ☐ Guardian ☐ CAS

Parent/Guardian Information
☐ Pickup Access
Relationship to Student __________________ Cell Number ___________________
☐ Access to Records
Parent/Guardian

☐ Marks Mail
Legal First Name _______________________ Home Number _________________
☐ Incidents Mail
☐ Other Mail
Legal Middle Name(s) ___________________ Work Number __________________
☐ Speaks Language
of School Legal Last Name _______________________ Email ________________________
☐ Lives With Student or ☐ Other Address _____________________________________________________
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☐ Pickup Access
Relationship to Student __________________ Cell Number ___________________
☐ Access to Records
Parent/Guardian

☐ Marks Mail
Legal First Name _______________________ Home Number _________________
☐ Incidents Mail
☐ Other Mail
Legal Middle Name(s) ___________________ Work Number __________________
☐ Speaks Language
of School Legal Last Name _______________________ Email ________________________
☐ Lives With Student or ☐ Other Address _____________________________________________________
*TVDSB recommends families consider a local resident
as one of the assigned contacts for emergency purposes*
Additional/Emergency Contact Information
☐ Pickup Access
Relationship to Student __________________ Cell Number ___________________
☐ Access to Records
☐ Marks Mail
Contact #1

Legal First Name _______________________ Home Number _________________

☐ Incidents Mail
☐ Other Mail
Legal Middle Name(s) ___________________ Work Number __________________
☐ Speaks Language
of School Legal Last Name _______________________ Email ________________________
☐ Lives With Student or ☐ Other Address _____________________________________________________
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☐ Pickup Access
Relationship to Student __________________ Cell Number ___________________
☐ Access to Records
☐ Marks Mail
Contact #2

Legal First Name _______________________ Home Number _________________

☐ Incidents Mail
☐ Other Mail
Legal Middle Name(s) ___________________ Work Number __________________
☐ Speaks Language
of School Legal Last Name _______________________ Email ________________________
☐ Lives With Student or ☐ Other Address _____________________________________________________
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Any Additional Contact(s): _________________________________________________________________

Parent/Guardian/Contact Priority
1. ____________________________________ 1. ____________________________________
School Closure
Emergency/
Sickness/
Medical

2. ____________________________________ 2. ____________________________________

3. ____________________________________ 3. ____________________________________

4. ____________________________________ 4. ____________________________________
 Siblings
Sibling Name School Name Date of Birth (YYYY-MM-DD)
______________________________ _______________________________ ________-_____-_____

______________________________ _______________________________ ________-_____-_____

______________________________ _______________________________ ________-_____-_____

______________________________ _______________________________ ________-_____-_____

Permissions / Waivers
For every student an Ontario Student Record (OSR) folder is maintained; This is a record of the student’s school history.
Students and parent/guardians of students under the age of 18, unless they are denied by a court order, have access to
the OSR and can confer with school officials regarding its contents. Initials: _____
Notice of Collection: The personal information provided on this pre-registration form and any other correspondence
relating to involvement in Board programs is collected by the Thames Valley District School Board (TVDSB) under the
authority of the Education Act and Regulations (R.S.O. 1990 cE.2) as amended. The information will be used to register
the student in a school, for the collection of applicable student/activity fees, as well as for any consistent purpose.
Information is shared with employees such that they may carry out their job duties. In addition, the information may be
used or disclosed to comply with legislation, for compelling circumstances affecting health and safety or discipline, as
required in circumstances related to law enforcement matters, or in accordance with any other Act. For questions about
this collection, contact the Board’s Freedom of Information Coordinator
Initials: _____
It is the parent/guardian’s responsibility to provide the school with written notification of relevant health and custody
access information. Initials:
_____
The transfer of student records contained in the OSR from your child’s former school/district can take some time. If your
child has any special concerns, either physically, academically, or behaviourally, communication between the former
school and the new school prior to the delivery their records is required to meet your child’s needs. Information to be
shared includes, but is not exclusive to, the contents of the OSR. This information is obtained and used only for the
improvement of instruction and other education of the student in accordance with the Education Act (R.S.O. 1990,
s.266(2)), and is collected, transmitted, retained, and disposed of confidentially in accordance with the Municipal Freedom
of Information and Protection of Privacy Act (R.S.O. 1990 c. M. 56). Permission is granted for one year from the date of
signing. I give permission for the Principal/Designate of the new school and former school to communicate and share
information with each other in regard to the programming needs for my child.
Initials: _____
Signature Verifying all information submitted is accurate.

______________________________ _________________________ _____________________

Parent/Guardian Name Printed Signature Date

Office Use
☐ Student plans to attend French Immersion in Grade One ☐ Student would like to attend the APPLE Program
Proof of Birth (POB) Proof of Address (POA) Custody Court Documents
☐ Lease Agreement / Current
☐ Birth Certificate ☐ Custody Agreement
Agreement of Purchase and Sale
☐ Registration of Birth ☐ Current Utility Bill ☐ Court Order
☐ Passport ☐ Current Property Tax Bill Students Born Outside Canada
☐ Baptismal Certificate ☐ Current Phone/Cable/Internet Bill ☐ First Date of Entry Form
☐ Other: ___________________ ☐ Other*: _______________________ Note: *Driver’s License is not acceptable POA

I hereby confirm that the document(s) indicated above have been viewed and the student information
provided is correct.
______________________________ _________________________ _____________________
Staff Name Printed Signature Date