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Tsawout Language House Application Form
Tsawout Language House Application Form
docmedia
2021-09-24T21:24:47-07:00
SȾÁUTW SENĆOŦEN,ÁUTW (Tsawout Language House)
"
*
" indicates required fields
Step
1
of
2
50%
Registration Form
Please note: This form is confidential when completed.
My Child is a:
*
Infant
3 - 5 Years
Date of Registration
*
Month
Day
Year
Child / Children
Name of Child
*
First
Middle
Last
Name Child Responds to
*
SENĆOŦEN Name
Status Band Number
Street Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Mailing Address Same as Above?
*
Yes
No
Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Sex
*
Male
Female
Birthdate
*
Day
Month
Year
Child's First Language
*
Second Language
Would you like to add another child?
*
Yes
No
Name of Child
*
First
Middle
Last
Name Child Responds to
*
SENĆOŦEN Name
Status Band Number
Address Same as Child 1
*
Yes
No
Street Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Mailing Address Same as Above?
*
Yes
No
Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Sex
*
Male
Female
Birthdate
*
Day
Month
Year
Child's First Language
*
Second Language
Parent / Guardian 1
Name
*
First
Last
Place of Work
*
Phone
*
Local
Home Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Parent / Guardian 2
Name
First
Last
Phone
Local
Home Address Same as Guardian 1
*
Yes
No
Home Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Medical Information
Child's Name
Personal Health Number
*
Family Doctor
*
Phone
Family Dentist
*
Phone
Please indicate known health problems of child
On Medication
*
Yes
No
List Medication & Instructions
Allergies
*
Yes
No
List Allergies & Instructions
Vision/hearing problems
*
Yes
No
Explain Vision/hearing problems
Special Diet
*
Yes
No
Explain Special Diet
Indicate any accident, illness or medical disabilities your child has had (give dates)
Add Additional Child's Medical Information
*
Yes
No
Child's Name
Personal Health Number
*
Family Doctor
*
Phone
Family Dentist
*
Phone
Please indicate known health problems of child
On Medication
*
Yes
No
List Medication & Instructions
Allergies
*
Yes
No
List Allergies & Instructions
Vision/hearing problems
*
Yes
No
Explain
Special Diet
*
Yes
No
Explain
Indicate any accident, illness or medical disabilities your child has had (give dates)
Parent / Guardian Signature
Parent/Guardian Signature
*
Date
*
Month
Day
Year
Consent to Share and Exchange Information, Field-trip, Photograph & Videos, Community Health Nurse/Worker Visits
Consent to Share and Exchange Information
*
By checking this box, you are confirming your signature.
I authorize staff member(s) of the Tsawout Language House to discuss information as required for the purposes of my involvement in the program.
I understand that before any information is released to another agency/service provider, I will be consulted as to what information will be shared.
This consent will expire at the end or upon my withdrawal from the program.
Signature
Date
*
Month
Day
Year
Δ
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