Upper Grand District School Board
International Student Program
STUDENT APPLICATION
STUDENT/APPLICANT INFORMATION
Family Name
Given Names
Student’s Home Address (in home country):
Address:
Gender


Country of Birth
Male
Female
Date of Birth (dd/mm/yyyy)
____________________________
City:
Citizenship: __________________
Province:
First Language: _______________
Country:
Telephone (Home):
Zip Code
PARENT INFORMATION
Father’s Family Name / Given Name
Mother’s Family Name / Given Name:
Second Language: ____________
Student’s E-mail:
Father’s Contact Information
Telephone (home):
Cell:
E-mail:
Mother’s Contact Information
Telephone (home):
Cell:
E-mail:
Telephone (work):
Telephone (work):
Parent’s Address:
Address:
City:
Province:
Zip Code
Country:
CUSTODIANSHIP: The custodian must be over 19 years of age, a Canadian citizen or a permanent resident of Canada
and has agreed to take responsibility for the student. Custodian documents must be notarized.
Do you have a custodian in the Upper Grand District School Board area?
 Yes. If yes, please provide the information below.
Custodian’s Family / Given Name:
Custodian’s Address: (include postal code)
Relationship to Student:
Telephone (home):
Telephone (work):
Cell:
E-mail:
 No. If you require assistance to find a custodian, visit our website: http://www.ugdsb.on.ca/world/article.aspx?id=31731
ADDRESS IN UPPER GRAND DISTRICT SCHOOL BOARD
Do you have an address where you will live in the Upper Grand District School Board area?
 Yes. If yes, please provide the information below.
Name:
Telephone (home):
Telephone (work):
Cell:
E-mail:

Address:
(include postal code)
No. If you require assistance to find a homestay, visit our website: http://www.ugdsb.on.ca/world/article.aspx?id=31731
Student Application UGDSB 2016
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Upper Grand District School Board
International Student Program
STUDENT APPLICATION
STUDENT’S SCHOOL INFORMATION
Current School Name:
Current School Address: (City and Country)
Last Grade Completed:
Previous Year Average:
Language of instruction in current school:
Current Grade Enrolled:
Current Year Average:
Years of study of the English language:
Has the student ever attended a school in Canada? If yes, where and when?
SCHOOL PLACEMENT
Please visit our website http://www.ugdsb.on.ca/world/article.aspx?id=31734 for a list of schools. Final school placement is
subject to the student’s English level, academic interests, school capacity and homestay arrangement.
Upper Grand District School Board reserves the right to determine final school and grade placement.
The student is applying for the following term: (please check appropriate box)
Elementary (Junior Kindergarten to Grade 8)
Secondary (Grade 9 – Grade 12)








September – June
January – December
January – June
September – December
Summer Orientation & Leadership Camp (last 2 weeks of August)
□September – January
September – June
February – June
February – January
Indicate how long the student plans to study in Upper Grand
Indicate how long the student plans to study in
Upper Grand District School Board: __________
District School Board: ___________
Indicate three secondary school preferences:
1. ___________________ Why is this school your first choice?
_________________________________________________
2. ___________________
3. ___________________
Specialties :
Favourite Subjects: ______________________
Least Favourite Subjects: _________________
Strengths/Awards: ______________________
Hobbies/Interests:
_
What are the student’s goals:





Graduate from high school
Develop English skills only
Attend university in Canada
Attend college in Canada
Return to their home country
How did you hear about Upper Grand District School Board’s International Program?



Upper Grand District School Board website
Agent Name of agent & agency: _______________________________


Family or Friend
Education Fair
Other _____________________________________________________
An NON-REFUNDABLE application fee of $200 CDN must be submitted with the application. The fee, payable to
“Upper Grand District School Board”, can be paid by electronic transfer, bank draft, money order or certified
cheque. Fees are subject to change without notice.
I confirm that the information contained on the application form and all documents submitted in support of this application
are true and accurate, and I agree to pay the application fee at this time.
________________________________________________ _____________________
Student’s Signature
Date
_______________________________________________________ _________________________
Parent’s Signature
Date
Student Application UGDSB 2016
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Upper Grand District School Board
International Student Program
STUDENT APPLICATION
STUDENT PARTICIPATION AGREEMENT
A condition to the student admission and participation as an international student with the Upper Grand District School
Board (UGDSB) is that you agree to comply with all requirements outlined below. Further you accept the UGDSB’s
refund protocol as outlined.
In addition, it is agreed that:
1. It is the student’s responsibility to maintain a current Study Permit from Citizenship and Immigration Canada.
2. Tuition fees must be paid in full prior to a Letter of Acceptance being issued.
3. The student is required to maintain continuous Health Insurance coverage.
4. The student must observe and adhere to the following:
all federal, provincial and municipal laws of Canada.
the rules, policies and regulations of UGDSB.
the school’s Code of Conduct.
5. The student is expected to attend school regularly, meet homework expectations and maintain an acceptable
academic standing.
6. Regardless of the student’s age, information on the student’s attendance, academics and emotional, medical
and psychological concerns can be shared with parents, custodians/guardians, school and board staff in order
that necessary guidance and assistance can be provided.
7. It is the student’s/family of the student’s/custodian/homestay coordinator’s responsibility to contact the
International Student Program Office if there is any change to custodianship, change of homestay, address,
telephone number or emergency contact.
Failure to follow any of the above terms is subject to discipline measures and may result in the student being removed
from school and the UGDSB International Student Program without refund of tuition fee and/or any other
compensation. In this situation, it is expected that the student would return to their home country.
I confirm I have read, understand and agree to follow the requirements of the Student Participation Agreement.
Regardless of the student’s age, both the student and parent must sign this form.
_
Student’s Name (Printed)
_
Student’s Signature
_
Parent’s Signature
__
_
Date
_
Date
Student Application UGDSB 2016
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Upper Grand District School Board
International Student Program
STUDENT APPLICATION
TERMS and CONDITIONS
1. Any inaccuracy in the application may result in dismissal from the UGDSB without refund of tuition fee and/or any
other compensation.
2. UGDSB is not liable for an y loss, expense or injury suffered by the student including periods of study and travel. If
the student becomes ill or incapacitated, the UGDSB may take such action at the student’s expense as it considers
necessary, including securing medical treatment and transporting the student home.
3. UGDSB is not liable for losses or expenses as a result of the board being unable to provide education owing,
including interruptions caused by labour disputes, inclement weather conditions or other causes beyond its control.
4. The undersigned agrees to purchase Health Insurance to cover the duration of the student’s study within the
UGDSB.
5. The undersigned agrees to indemnify UGDSB for any damage, expense or injury incurred, resulting from the
student’s willful or negligent behaviour or actions.
I confirm I have read, understand and agree to follow the requirements of the Terms and Conditions.
Regardless of the student’s age, both the student and parent must sign this form.
_
Student’s Name (Printed)
_
Student’s Signature
_
Date
_
Parent’s Signature
_
Date
Student Application UGDSB 2016
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Upper Grand District School Board
International Student Program
STUDENT APPLICATION
FIELD TRIP AUTHORIZATION
Field trips and educational activity programs involve certain elements of risk. Injuries may occur while participating in
field trips and activity programs. The risk of sustaining injuries results from the nature of the field trip or activity and
can occur without any fault of the student or the school, its employees/agents or the facility where the field trip or
activity is taking place. By choosing to take part in the UGDSB International Student Program you are accepting the
risk that you/your child may be injured. The chance of an injury occurring can be reduced by the student carefully
following instructions at all times while on a field trip or participating in any activity.
I confirm that I have read, understand and agree to participate in field trips and educational activity programs as
arranged by the school or the UGDSB International Student Program.
Regardless of the student’s age, both the student and parent must sign this form.
_
Student’s Name (Printed)
_
Student’s Signature
_
Date
_
Parent’s Signature
_
Date
Student Application UGDSB 2016
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Upper Grand District School Board
International Student Program
STUDENT APPLICATION
CONSENT FOR PHOTO/VIDEO RELEASE
I hereby give permission to the UGDSB to use stories, quotes, photographs, video and electronic or other images for
publicity and promotional purposes during the school year and in future school years as required.
Stories and photographs may be distributed to news media, used in community reports and promotional materials,
displayed on the Internet using websites maintained by the UGDSB, and/or kept in the stock photo file. The UGDSB
does not sell names or photographs. In every instance, the board strives to present people in a complimentary and
appropriate manner. Accreditation for photographs, videos, student work etc. will be given as applicable.
I relinquish all rights, title, and interest I may have in above material and hereby release the UGDSB and its
employees, volunteers, servants and agents by agreeing that they shall not be liable for any and all claims or
demands for damages of any kind whatsoever arising from the UGDSB’s use of said material.
I confirm that I have read, understand and agree to give consent for stories, quotes, photographs, video and
electronic or other images as arranged by the school or the UGDSB International Student Program.
Regardless of the student’s age, both the student and parent must sign this form.
_
Student’s Name (Printed)
_
Student’s Signature
_
Date
_
Parent’s Signature
_
Date
Authorization for the collection and maintenance of this information is in keeping with the Education Act. The information
will be used to establish the student’s Ontario Student Record folder. The record of a student’s educational progress
through the schools in Ontario is maintained in the Ontario School Record (OSR) folder for that student. The contents of
the OSR folder are privileged for the information and use of supervisory officers, the Principal or designate, and the
Teachers of the school as well as the International Student Program Office, the Superintendent of Finance and relevant
support staff. Material contained in the OSR is to be used for the improvement of the instruction of the student. Each
student and the parent(s) (barring any court orders denying access) or guardian(s) of a student who is not an adult
(under the age of 18) have access to the student’s OSR. It is necessary to make an appointment with the Principal to
review the contents of an OSR. This form is attached to copies of Immigration documents qualifying the student for
admission to school. This form is kept for the duration of the OSR. Subsequent registration/verification forms that are
used for verification or change of existing information are kept until superseded.
Questions about this collection should be directed to the Principal or Superintendent of Education, Upper Grand District
School Board, 500 Victoria Road North, Guelph N1E 6K2, (519) 822‐4420. Some information contained in this form will
be shared with the Medical Officer of Health as outlined in the Education Act and the Immunization of School Pupils Act.
Student Application UGDSB 2016
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