Student Information Form Page 2
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1
2Emergency Contact Information
Emergency Contact 1 (if parents/guardians cannot be reached)
Last Name
First Name
Relationship to Student
Home Phone
Work Phone
Cell Phone
Language Spoken
Emergency Contact 2 (if parents/guardians cannot be reached)
Last Name
First Name
Relationship to Student
Home Phone
Work Phone
Cell Phone
Language Spoken
Student Medical Health Information
Doctor Name
Doctor Phone
Care Card #
Special Medical Concerns?
Yes
No
If yes, please list details on the District Medical Information Forms
Immunization Records – Photocopies Attached?
Yes
No
Sibling Information (
Only Siblings attending schools or StrongStart programs within the Burnaby School District)
Sibling 1 Last Name
First Name
Male
Female
Birthdate
Sibling 2 Last Name
First Name
Male
Female
Birthdate
Sibling 3 Last Name
First Name
Male
Female
Birthdate
The information on this form is collected under the authority of the School Act, Sections 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 Privacy Act. If you have any questions about the
information recorded on this form, please contact the School Administration.
I certify that the information provided on this form is correct and valid of this date.
Parent / Guardian Signature _____________________________________________ Date ______________________________
Administrator’s Signature _______________________________________________ Date ______________________________
Information and Documentation – For Office Use Only
Admission Status
Documents/Attachments
Student Resides in School Attendance Area
Proof of Citizenship/Immigration Status
Student Attends Licensed Childcare in School Attendance Area
Proof of Age
Birth Certificate
Passport
Other
Cross District Transfer
Proof of Residency
Proof of Licensed Childcare Address
District Language Program Applicant
Copy of Legal Alert/Court Orders
Medical Alert Forms Filled out (if applicable)
English Language Assessment Required
Student Info Form Jan 2016
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