Cedar StrongStart Registration Form - Campbell River School District

StudentRegistrationFormStudent No: Medical Alert Legal AlertCedar StrongStart Program261 Cedar St., Campbell River, B.C. V9W 2V3Tel: (250) 287-8335 • Fax: (250) 286-0378cedar@sd72.bc.caStudent Information - please printDate of Form Completion:Name:Last Name First Name MiddleGrade:Legal Name (if different than above):Sex: Age: Date of Birth: Birth Certificate Attached:Month Day YearCross Boundary: Yes No From:Other family members registered at this school:Ages of preschool children:Student’s Address:Postal Code:Home Phone Number:Mailing Address (if different):Postal Code:Parent(s) / Guardian(s) with whom the student resides - please list in order of whom to contact first if the child is sick:Employer:Last NameFirst NameRelationship:Work Phone Number:Cell Number:Email:Last NameAddress (if different than above):Employer:First NameRelationship:Work Phone Number:Cell Number:Email:Parent(s) / Guardian(s) with whom the student DOES NOT reside:Address:Employer:Last NameFirst NameRelationship:Home Phone Number:Work Phone Number:Cell Number:Email:Court Order in Effect?: Yes No If yes, copy of custody order attached:Who has legal access to the child?:Custody arrangement:Revised January 2014School District 72 • Campbell River, B.C.Page 1 of 2 (see over for page 2)

Emergency Information - please printName and number of two relatives / friends to contact in case of an emergency:Name:Relationship:Name:Relationship:Name of daycare (if applicable):Phone:Cell Phone:Phone:Cell Phone:Phone:Health InformationFamily doctor:Phone:Family dentist:Provincial Care Card Number:Clinic:Phone:Heart Problems Diabetes Epilepsy Physical Disabilities Hearing VisionAllergiesOther:Anaphylaxis and/or history of severe allergic responseBlood clotting disorders such as hemophilia that requires immediate medical careSevere asthma - immediate medical treatment requiredOther conditions which may require emergency care:This child is currently on regular medication for:Medication names:Can this child take part in regular physical activities?: YesNoOther relevant information:Special Assistance Has this child received any of the following special services?Learning Assistance English as a 2nd Language Speech Therapy Physiotherapy GiftedOther:Language(s) spoken at home:Are you of First Nations ancestry? Yes No Status? Yes NoDo you live on reserve? Yes No Band Affiliation:Métis Ancestry Métis Nation Citizen (Status) Inuit AncestryPrevious School Name & address of previous schoolPublic SchoolPrivate SchoolFor Office Use:Bus Student: Yes No Bus #:Assigned to: Div. #: Rm. #: Teacher:Revised January 2014School District 72 • Campbell River, B.C. Page 2 of 2