Elementary School  Registration Form  

            WILLWAY ELEMENTARY SCHOOL

Student Information:

Gender: M/F: ___  Grade:____ LEGAL Surname: ________________________  LEGAL First Name: ____________________

Preferred Surname (if different): ________________________  Preferred First Name (if different): ________________

Middle Names (all): _______________________________Birthdate:  ___ / ___  / _________Proof of Age:  Birth Cert. __or _________

                                                                                                Day     Month     Year

Home Phone: ___________________ Address: _________________________________________________________

Mailing Address (if different) _____________________________________________           Postal Code: _______________

Last School Attended:____________________________________     Involved in:  Learning Assistance: _     ESL: _       

                        Special Education: __     Counselling: __     Speech & Language: __     French Immersion: __

Place of Birth: ___________________________________             Citizenship (if not Canadian): _______________________

Language:  First Language? _______________________             Language at Home?____________________________

Aboriginal Ancestry:  No: __  / Yes: __     Inuit: _    Metis: _     Non-Status: __    Status-OFF Reserve: _

                 Status-ON Reserve: __      Band of Residence Name: _________________      DIA Number: ________

Parent Information:

      Custody of:  Mother: _   Father: _    Both: __                    Living with:  Mother: _    Father: _    Both: _

      Court Order? No: _ / Yes: _      If Yes give details: (Note:  A copy of an up-to-date court order must be on file with the school.)

            __________________________________________________________________________________________

1)       Mother:    Last Name: _________________________________                      First Name: _______________________

Address (if different than student): __________________________________________________________________

Home Phone (if different): ______________      Work Phone: ______________      Cell Phone: _______________

Employer:  ____________________________              Email Address: _____________________________________

2)       Father:    Last Name: _________________________________                        First Name: _______________________

Address (if different than student): __________________________________________________________________

Home Phone (if different): ______________      Work Phone: ______________      Cell Phone: _______________

Employer:  ____________________________              Email Address: _____________________________________

Emergency Contacts:  (Parents will always be contacted first.  This list is for back up purposes.)

1)       Last Name: _____________________________                          First Name: ________________________________

Relationship: ____________­________      Home Phone: ______________     Cell/Work Phone: _____________

2)       Last Name: _____________________________                          First Name: _________________________________

Relationship: ____________­________      Home Phone: ______________     Cell/Work Phone: _____________

Daycare:  Name:  ______________________________             Phone: _______________           Cell Phone: _______________

Medical Information:

Doctor: ____________________________   Phone: _______________    Care Card #____________________________

Allergies/Health Conditions: ____________________________________________     Life Threatening?  Yes: _  / No: _

Is this child currently on medication: Yes: _ / No: _     Description: __________________________________________

Parent/Guardian Signature:  _____________________________________                  Date:  ________________