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Tsawout Language House Application Form

Tsawout Language House Application Formdocmedia2021-09-24T21:24:47+00:00

SȾÁUTW SENĆOŦEN,ÁUTW (Tsawout Language House)

"*" indicates required fields

Step 1 of 2

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Registration Form

Please note: This form is confidential when completed.
My Child is a:*
Date of Registration*

Child / Children

Name of Child*
Street Address*
Mailing Address Same as Above?*
Mailing Address
Sex*
Birthdate*
Would you like to add another child?*
Name of Child*
Address Same as Child 1*
Street Address*
Mailing Address Same as Above?*
Mailing Address
Sex*
Birthdate*

Parent / Guardian 1

Name*
Home Address*

Parent / Guardian 2

Name
Home Address Same as Guardian 1*
Home Address

Medical Information

Please indicate known health problems of child

On Medication*
Allergies*
Vision/hearing problems*
Special Diet*
Add Additional Child's Medical Information*

Please indicate known health problems of child

On Medication*
Allergies*
Vision/hearing problems*
Special Diet*

Parent / Guardian Signature

Reset signature Signature locked. Reset to sign again
Date*

Consent to Share and Exchange Information, Field-trip, Photograph & Videos, Community Health Nurse/Worker Visits

Consent to Share and Exchange Information*
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.
Reset signature Signature locked. Reset to sign again
Date*

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