Welcome to
Lester B. Pearson Catholic
Elementary School
Patron Blessed Teresa of Calcutta
Partners in Learning
Getting to Know your Child – School Entry Questionnaire
Dear Parents/Guardians: Thank you for taking the time to complete this school entry questionnaire. This will allow the school
to get to know your child better and assist in planning the most developmentally appropriate program for him/her. Should you
need assistance in the completion of this form, please contact the school principal.
Name of Child: __________________________________________________________
Preferred First Name: ____________________________________________________
Date of Birth: ___________________________________________________________
Family Information:
Parent’s Name: __________________________________ Phone number: ____________________________________
Parent’s Name: __________________________________ Phone number: ____________________________________
Child resides with:
Both Parents
Single Parent
Other
List your child’s siblings:
Name:________________________________ Age: ______ Name:________________________________ Age: ______
Name:________________________________ Age: ______
Before and/or After School Care:
Name:________________________________ Age: ______
Parent
Babysitter
Childcare Centre
Physical Health and Well Being:
Does your child have any allergies?
No
Yes
If yes, what is he/she allergic to? _____________________________________________________________________
Does your child require:
Epi Pen
Inhaler
Other
Does your child require any medication on a regular basis? ____________________________________________________
Does your child, or has your child had, a medical condition?____________________________________________________
___________________________________________________________________________________________________
Does it require medication or management at school? ________________________________________________________
___________________________________________________________________________________________________
In order to provide the best possible school experience and to help us to understand your child and his/her needs, please
indicate any of the screenings/assessments in which your child has participated:
Hearing
Occupational Therapy
Physiotherapy
Vision
Speech and Language
Pediatric Assessment
Has your child been referred to and/or received assistance from any community agencies?
Agency
Service Received
Erin Oak Kids Rehabilitation Services, primary team of
Physiotherapy, Occupational Therapy, Speech and
Language, Medical
Peel Preschool Speech and Language Services
Trillium Health Centre
Autism Intervention Services
(Preschool Autism Services)
Peel Infant and Child Development
Peel Behaviour Services
Peel Blind, Low Vision Services
Infant Hearing Program
Autism Intervention Services
Other
Other
At what stage is your child in self-toileting?
Working on Toilet Training
Does your child require a diaper or pull up?
Some assistance needed
No
Independent
Yes
Comments: _________________________________________________________________________________________
___________________________________________________________________________________________________
Is your child presently taking naps or having rest periods during the day?
No
Yes
If yes, please describe how long does he/she usually naps or rests? ____________________________________________
___________________________________________________________________________________________________
Comments: _________________________________________________________________________________________
___________________________________________________________________________________________________
Is your child comfortable with feeding himself/herself?
No
Yes
Comments: _________________________________________________________________________________________
___________________________________________________________________________________________________
What types of organized sports, social clubs, activities does your child enjoy in the community?________________________
___________________________________________________________________________________________________
What other kind of physical activity does your child enjoy? _____________________________________________________
___________________________________________________________________________________________________
Do you have any concerns about your child’s health and well-being? ____________________________________________
___________________________________________________________________________________________________
Social and Emotional Development
How would you describe your child’s temperament?
Easy going
Nervous in new situations
High energy
Shy with others
Other: _____________________________________________________________________________________________
Describe any situation in which your child becomes particularly excitable, upset, frightened or angry. ___________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
What techniques have you found that help to calm him/her down? ______________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
When your child is not cooperating, what kinds of child guidance strategies do you use to help him/her cooperate?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Has your child experienced any significant changes in his/her family life in the recent past? (e.g., death of family member,
moving, birth of a sibling, divorce)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Do you have any concerns about your child’s social and emotional development? __________________________________
___________________________________________________________________________________________________
Fine and Gross Motor Development
Does your child have experience with any of the following activities? (Check all applicable):
Using a pencil
Drawing, colouring, painting
Using crayons
Printing his/her name
Using scissors
Using plasticine, play dough
Fastening and unfastening buttons
Fastening and unfastening zippers
Fastening and unfastening shoes
At what stage is your child in self-dressing with outdoor clothing? (E.g. jacket, snow suit, shoes, boots):
Working on learning to self- dress
Some assistance needed
Independent
Other: ____________________________________________________________________________________________
Comments:__________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Language and Cognitive Development
What languages are spoken at home? ____________________________________________________________________
Which language is use most with the child? ________________________________________________________________
Does your child listen to simple stories?
No
Yes
Does your child speak in sentences of at least 4 to 5 words in your home language?
No
Does your child speak in sentences of at least 4 to 5 words in English?
Yes
Does your child ask a lot of questions?
No
No
Yes
Yes
Does your child enjoy (check all applicable)
Being read to?
Reciting Nursery Rhymes?
Singing songs?
Telling Stories?
Does your child like to watch television, play video games or play on the computer?
No
Yes
If yes, about how much time does your child spend each day in these activities? ___________________________________
___________________________________________________________________________________________________
Do you have any concerns about your child’s social and emotional development? __________________________________
___________________________________________________________________________________________________
School Readiness Skills
Does your child recognize letters of the English alphabet?
No
Yes
Does your child know some sounds letters make? (E.g. sound of the first letter of his/her name)
Does your child pick up a book and pretend to read?
No
(Reads the pictures, remembers the book from memory or tells own story)
No
Yes
Yes
Does your child read familiar environmental print on traffic signs, billboards, store fronts, labels, packaging? (e.g., STOP)
No
Yes
Does your child read in English?
No
Yes
Does your child read in another language?
No
Does your child count?
Yes
No
Does your child recognize any of the following?:
Numbers to 10
Basic Shapes (square, circle, triangle, rectangle)
Sizes (Big, Small)
Colours
Yes
Has your child participated in any early learning programs such as those offered in:
Early Learning Program
A Few Times
Monthly
Weekly
Daily
Ontario Early Years Centre
Licensed Day Care/Early Learning Centre
Home Daycare
Hub/Readiness Centre
Parenting/Family Literacy Centre
Public Library Program
Specialized program offered through
Health Services
(e.g., speech and language, behaviour
Other:
Other:
Do you have any concerns about your child’s school readiness? ______________________________________________
___________________________________________________________________________________________________
Is there any other additional information you would like to tell us to assist us with making your child more comfortable and
ready to transition to school?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Parent Engagement
It has long been acknowledged that parents, in collaboration with classroom educators, can make a contribution to the quality
of children’s learning experiences.
Do you have knowledge or skills that could you would like to contribute to your child’s program either during the school day
or at another time?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Kindergarten Registration Questionnaire
What is your child’s first and last name?________________________________
Is your child Male ___ or Female ___?
What is your child’s date of birth?____________________________________
What is your child’s current address? _________________________________
Does your child reside with both parents Yes ___ No ___. If no, with whom
does he or she reside? ____________________________________________
Does your child require any medication? ____ If yes, what medication does
he/she take? ___________________________________________________
Does your child have allergies? Yes ___ No ___ If yes, what allergies does
he/she have? ___________________________________________________
Does he/she require and EPI Pen? Yes ___ No ___
Does your child require any special needs or special considerations?
______________________________________________________________
______________________________________________________________
Is your child receiving speech therapy? Yes ___ No ___ Specify
_____________________________________________________________.
Is your child toilet trained? Yes ___ No ___
Does your child have any daycare experience? Yes ___ No ___ If yes, provide
specific information ______________________________________________.
Are you or your child experiencing any anxiety that may require extra support
during his or her staggered entry? Yes ___ No ___
______________________________________________________________
Parent Name: __________________________________
Home Phone: _____________ Work: _____________ Cell: ______________
Student Registration and Information Form - Elementary School
CANADA’S ANTI-SPAM LAW CONSENT
Under Canada’s Anti-Spam law (CASL) the Dufferin-Peel Catholic District School Board requires your consent to send
you electronic messages about commercial activities. While much of our email communication is about school, school
council or Board news and activities, we may also send electronic messages of a commercial nature. This would include
newsletters and other communications about such things as field trips, yearbooks, uniforms, school pictures, fundraising
activities and events, food and drink purchases, books, prom or dance tickets, sporting/athletic events or similar events
and offers.
The Mission of the Dufferin-Peel Catholic District School Board, in partnership with the family and church, is to
provide, in a responsible manner, a Catholic education which develops spiritual, intellectual, aesthetic, emotional,
social, and physical capabilities of each individual to live fully today and to meet the challenges of the future, thus
enriching the community.
STUDENT PERSONAL INFORMATION PART 1
If you wish to receive the above electronic communications from us, please provide your email address below. Your
consent remains in effect as long as the student attends a DPCDSB school unless you withdraw it. If you have any
questions, or wish to revoke your consent at any time please contact your school principal.
Legal Names: (Students are registered by their legal name which will be used on legal documents. The student’s preferred name will be used at school.)
Signature of Parent/Guardian:
Preferred Names:  Same as Legal Names, or
Email Address:
Surname:
Surname:
SIGNATURES
Gender:  Female
PLEASE NOTE: Falsifying information on this form may rescind the admission to this elementary school
Signature of Parent/Guardian:
Date:
Signature of Principal/Designate:
Date:
First Name:
Middle Name:
 Male
Birthdate:
Previous school attended:
Year
Month
Day
First day of entry to any school in Ontario:
Year
If the student is entering from outside of Ontario, please indicate name of
Information is collected under the authority of the Education Act, R.S.O. 1990, c. E.2, (s.170, s.190, s.264, s.265); Sabrina's Law,
2005, S.O. 2005, c. 7 and Ryan’s Law (Ensuring Asthma Friendly Schools), 2015, S.O. 2015, C. 3 in accordance with the
Municipal Freedom of Information and Protection of Privacy Act. Any questions regarding information collected, may be
directed to the school principal or to the Records Management and Access & Privacy Administrator, 40 Matheson Blvd West,
Mississauga, ON L5R 1C5 (905) 890-1221 ext. 24443
Month
Day
Territory/Province/Country
Does this student have sibling(s) in this District School Board? Yes No
If yes:  Elementary
Secondary
If yes, provide full name(s):
Does this student have sibling(s) in another District School Board?
Yes
No
If yes, state name of District School Board:
This student is the: only 
eldest 
youngest  in their family, at this school
Is this student Roman Catholic, or, in an Eastern Church in full communion with the Holy See of Rome? Yes No
Note: Students/Parents/Guardians registering at St. Sofia School must be baptized in the Byzantine Rite of the Roman Catholic Church
Office use only
School: Lester B Pearson Catholic School_ Grade: _____ Teacher: ______________ Start date:_____________
Documents to be filed in the OSR:
 Newcomer Reception Report
 P.E.D.S. (Personal Electronic Device) Agreement
 Application for Direction of School Support/Lease
 IPRC Documentation
 Baptismal Certificate of Student
 IEP Documentation
 Baptismal Certificate of Parent/Guardian (if applicable)
 Medication Forms
 Confirmation of Pupil Eligibility (GF008.1)
 Flex Boundary Documentation
 Registration form
 Network User Agreement
 Copy of most recent Custody Order if applicable (original document to be viewed and verified)
Original documents to be viewed and verified but not filed in the OSR
 Birth Certificate
 Citizenship/Immigration/Intl. Student Verification
 Immunization Certificate or Statement of Medical Exemption (copy only sent to Peel Health)
 Proof of Residence Source: ___________________________________
(e.g., property tax bill, current utility bill, real estate document, or Government of Canada issued forms)
Office Signature_______________________________________
Page 4
Middle Name:
Previous School Board: ________________________________
Personal information collected shall be used to establish and/or maintain the student’s Ontario Student Record (OSR) for the
provision of educational services and to administer health and/or medical emergency responses to the student as required. In
keeping with the requirements of the Education Act, the OSR and other information required to establish an appropriate program
for the student shall be requested from the student’s former school.
CC: Copy to be filed in the OSR
First Name:
If yes, provide an original Roman Catholic Baptismal Certificate.
If yes: Date of Baptism:
Year
If no, specify who is Catholic*:
Month
Day
 Mother
If no, receive Sacramental Preparation Letter from school
Church and City:
 Father
 Legal Guardian
*Note: An original Roman Catholic Baptismal Certificate of one of the parents/guardians must be provided at the time of registration of the student.
Medical Condition(s)/Alert:
Custody Information
Who has legal custody?
 Both parents
 Father only
 Mother only
Are there any special arrangements pertaining to access/visitation?  Yes
 Other
 No
If yes, then the most recent original Court Order to support custody must be provided (a verified copy to be stored in the OSR)
GF 008 E
Revised Oct 15
Page 1
GF 008 E
Revised Oct 15
Caregiver Contact: (Complete this section if child care is provided at a different address from the student’s.)
STUDENT PERSONAL INFORMATION PART 2
Student’s Country of Birth:
Arrival Date (into Canada):
Year
Month
Day
Expiry Date (if applicable):
Year
Month
Name of Caregiver
Day
If arrived within the past five years, complete the ‘Confirmation of Pupil Eligibility . . .’ form (GF008.1).
Caregiver
Relationship to Student
Status in Canada: (√ one) ☐ Canadian Citizen
☐ Permanent Resident
☐ Permanent Resident Pending ☐ Temporary Resident
☐ International Student
☐ Parent on Study Permit
Phone: (
Country of Last Residence:
☐ Refugee
☐ Parent on Work Permit
☐ Student on Study Permit
Country of Citizenship:

 Métis
Alternate Phone: (
Street
)
 Speaks English
Last Name
Relationship to Student
Address:  Same as student or
Home Phone:  Same as student or (
)
Business Phone:(
)
Ext.
)
ADDITIONAL INFORMATION
Unit Type (e.g. Apt.)
(
City
Last Name
Gender:  Female  Male
First Name
STUDENT ADDRESS
Number
First Name
Emergency Contact (other than parent/guardian/caregiver):
Cell Phone: (
 First Nation Métis and Inuit Ancestry
 Speaks English
Address:
)
Title
ABORIGINAL STUDENT (Voluntary Self-Identification): For the purposes of supporting First Nation, Métis and
Inuit student achievement objectives of Dufferin-Peel and the Ministry of Education, and of reporting student
achievement to the Ministry of Education and the Education Quality and Accountability Office, I / we choose to
voluntarily self-identify my/this child’s ancestry as:
 Inuit
Title
Or
Emergency Priority (Circle one): 1 2 3 4
Note: If new to Ontario, please provide the school with a copy of the student’s most recent Report Card.
 First Nations
Gender:  Female Male
Emergency Priority (Circle one): 1 2 3 4
If Canada, Province of Birth:
Language(s) spoken by student:
Unit #
)
Postal Code
Phone #
Mailing Address (if different from above):
 Proof of Residence Source: ___________________________________________________
 First Language
 Spoken at Home
Remark:
 First Language
 Spoken at Home
Remark:
Special Education:
(e.g., property tax bill, current utility bill, real estate document, or Government of Canada issued forms)
 Yes  No
Does student have special education/diverse learning needs?
Please indicate if this student: lives in a group home
Is enrolled in a Care, Treatment, Custody, Corrections (CTCC) program?
Yes No
Yes No
Does student have specialized equipment?
 Yes  No
SEA
 Yes  No
In your previous school/board, was this student involved in special education programs and/or services?  Yes  No
PARENTAL/GUARDIAN CONTACT INFORMATION
Emergency Priority (Circle one): 1 2 3 4
Title
First Name
Separate School Supporter: Yes No
Last Name
Does this student have an Individual Education Plan (IEP)?
Speaks English 
Relationship to Student
Home Phone: Same as student or
Cell Phone: (
(
)
)
Business Phone (
Alternate Phone: (
Emergency Priority (Circle one): 1 2 3 4
Title
)
Ext.
In your previous school/board, did this student receive ESL/ELD services?
Last Name
Speaks English

Relationship to Student
Address:  Same as student or
Cell Phone: (
)
Yes  No
English Language Learners (ELL)
)
Separate School Supporter: Yes No
First Name
Home Phone:  Same as student or (
Has this student been identified as an exceptional student, through the Identification Placement Review Committee
(IPRC)?
Yes  No
If yes, date of most recent IPRC review, as appropriate: __________________________________
Is the student’s transition plan attached to the IEP?
Address:  Same as student or
)
Business Phone:(
Alternate Phone: (
Page 2
)
Yes  No
)
Ext.
Yes No
SAFE SCHOOLS
Suspension/Expulsion
1. Is the student being registered currently serving a suspension?
2. Is the student being registered currently participating in a program for suspended students?
3. Is the student being registered expelled from any school and, if yes, have they successfully
completed a program for expelled students? ____________________________________
Yes No
Yes No
Yes
No
Ext.
GF 008 E
Revised Oct 15
Page 3
GF 008 E
Revised Oct 15
Caregiver Contact: (Complete this section if child care is provided at a different address from the student’s.)
STUDENT PERSONAL INFORMATION PART 2
Student’s Country of Birth:
Arrival Date (into Canada):
Year
Month
Day
Expiry Date (if applicable):
Year
Month
Name of Caregiver
Day
If arrived within the past five years, complete the ‘Confirmation of Pupil Eligibility . . .’ form (GF008.1).
Caregiver
Relationship to Student
Status in Canada: (√ one) ☐ Canadian Citizen
☐ Permanent Resident
☐ Permanent Resident Pending ☐ Temporary Resident
☐ International Student
☐ Parent on Study Permit
Phone: (
Country of Last Residence:
☐ Refugee
☐ Parent on Work Permit
☐ Student on Study Permit
Country of Citizenship:

 Métis
Alternate Phone: (
Street
)
 Speaks English
Last Name
Relationship to Student
Address:  Same as student or
Home Phone:  Same as student or (
)
Business Phone:(
)
Ext.
)
ADDITIONAL INFORMATION
Unit Type (e.g. Apt.)
(
City
Last Name
Gender:  Female  Male
First Name
STUDENT ADDRESS
Number
First Name
Emergency Contact (other than parent/guardian/caregiver):
Cell Phone: (
 First Nation Métis and Inuit Ancestry
 Speaks English
Address:
)
Title
ABORIGINAL STUDENT (Voluntary Self-Identification): For the purposes of supporting First Nation, Métis and
Inuit student achievement objectives of Dufferin-Peel and the Ministry of Education, and of reporting student
achievement to the Ministry of Education and the Education Quality and Accountability Office, I / we choose to
voluntarily self-identify my/this child’s ancestry as:
 Inuit
Title
Or
Emergency Priority (Circle one): 1 2 3 4
Note: If new to Ontario, please provide the school with a copy of the student’s most recent Report Card.
 First Nations
Gender:  Female Male
Emergency Priority (Circle one): 1 2 3 4
If Canada, Province of Birth:
Language(s) spoken by student:
Unit #
)
Postal Code
Phone #
Mailing Address (if different from above):
 Proof of Residence Source: ___________________________________________________
 First Language
 Spoken at Home
Remark:
 First Language
 Spoken at Home
Remark:
Special Education:
(e.g., property tax bill, current utility bill, real estate document, or Government of Canada issued forms)
 Yes  No
Does student have special education/diverse learning needs?
Please indicate if this student: lives in a group home
Is enrolled in a Care, Treatment, Custody, Corrections (CTCC) program?
Yes No
Yes No
Does student have specialized equipment?
 Yes  No
SEA
 Yes  No
In your previous school/board, was this student involved in special education programs and/or services?  Yes  No
PARENTAL/GUARDIAN CONTACT INFORMATION
Emergency Priority (Circle one): 1 2 3 4
Title
First Name
Separate School Supporter: Yes No
Last Name
Does this student have an Individual Education Plan (IEP)?
Speaks English 
Relationship to Student
Home Phone: Same as student or
Cell Phone: (
(
)
)
Business Phone (
Alternate Phone: (
Emergency Priority (Circle one): 1 2 3 4
Title
)
Ext.
In your previous school/board, did this student receive ESL/ELD services?
Last Name
Speaks English

Relationship to Student
Address:  Same as student or
Cell Phone: (
)
Yes  No
English Language Learners (ELL)
)
Separate School Supporter: Yes No
First Name
Home Phone:  Same as student or (
Has this student been identified as an exceptional student, through the Identification Placement Review Committee
(IPRC)?
Yes  No
If yes, date of most recent IPRC review, as appropriate: __________________________________
Is the student’s transition plan attached to the IEP?
Address:  Same as student or
)
Business Phone:(
Alternate Phone: (
Page 2
)
Yes  No
)
Ext.
Yes No
SAFE SCHOOLS
Suspension/Expulsion
1. Is the student being registered currently serving a suspension?
2. Is the student being registered currently participating in a program for suspended students?
3. Is the student being registered expelled from any school and, if yes, have they successfully
completed a program for expelled students? ____________________________________
Yes No
Yes No
Yes
No
Ext.
GF 008 E
Revised Oct 15
Page 3
GF 008 E
Revised Oct 15
Student Registration and Information Form - Elementary School
CANADA’S ANTI-SPAM LAW CONSENT
Under Canada’s Anti-Spam law (CASL) the Dufferin-Peel Catholic District School Board requires your consent to send
you electronic messages about commercial activities. While much of our email communication is about school, school
council or Board news and activities, we may also send electronic messages of a commercial nature. This would include
newsletters and other communications about such things as field trips, yearbooks, uniforms, school pictures, fundraising
activities and events, food and drink purchases, books, prom or dance tickets, sporting/athletic events or similar events
and offers.
The Mission of the Dufferin-Peel Catholic District School Board, in partnership with the family and church, is to
provide, in a responsible manner, a Catholic education which develops spiritual, intellectual, aesthetic, emotional,
social, and physical capabilities of each individual to live fully today and to meet the challenges of the future, thus
enriching the community.
STUDENT PERSONAL INFORMATION PART 1
If you wish to receive the above electronic communications from us, please provide your email address below. Your
consent remains in effect as long as the student attends a DPCDSB school unless you withdraw it. If you have any
questions, or wish to revoke your consent at any time please contact your school principal.
Legal Names: (Students are registered by their legal name which will be used on legal documents. The student’s preferred name will be used at school.)
Signature of Parent/Guardian:
Preferred Names:  Same as Legal Names, or
Email Address:
Surname:
Surname:
SIGNATURES
Gender:  Female
PLEASE NOTE: Falsifying information on this form may rescind the admission to this elementary school
Signature of Parent/Guardian:
Date:
Signature of Principal/Designate:
Date:
First Name:
Middle Name:
 Male
Birthdate:
Previous school attended:
Year
Month
Day
First day of entry to any school in Ontario:
Year
If the student is entering from outside of Ontario, please indicate name of
Information is collected under the authority of the Education Act, R.S.O. 1990, c. E.2, (s.170, s.190, s.264, s.265); Sabrina's Law,
2005, S.O. 2005, c. 7 and Ryan’s Law (Ensuring Asthma Friendly Schools), 2015, S.O. 2015, C. 3 in accordance with the
Municipal Freedom of Information and Protection of Privacy Act. Any questions regarding information collected, may be
directed to the school principal or to the Records Management and Access & Privacy Administrator, 40 Matheson Blvd West,
Mississauga, ON L5R 1C5 (905) 890-1221 ext. 24443
Month
Day
Territory/Province/Country
Does this student have sibling(s) in this District School Board? Yes No
If yes:  Elementary
Secondary
If yes, provide full name(s):
Does this student have sibling(s) in another District School Board?
Yes
No
If yes, state name of District School Board:
This student is the: only 
eldest 
youngest  in their family, at this school
Is this student Roman Catholic, or, in an Eastern Church in full communion with the Holy See of Rome? Yes No
Note: Students/Parents/Guardians registering at St. Sofia School must be baptized in the Byzantine Rite of the Roman Catholic Church
Office use only
School: Lester B Pearson Catholic School_ Grade: _____ Teacher: ______________ Start date:_____________
Documents to be filed in the OSR:
 Newcomer Reception Report
 P.E.D.S. (Personal Electronic Device) Agreement
 Application for Direction of School Support/Lease
 IPRC Documentation
 Baptismal Certificate of Student
 IEP Documentation
 Baptismal Certificate of Parent/Guardian (if applicable)
 Medication Forms
 Confirmation of Pupil Eligibility (GF008.1)
 Flex Boundary Documentation
 Registration form
 Network User Agreement
 Copy of most recent Custody Order if applicable (original document to be viewed and verified)
Original documents to be viewed and verified but not filed in the OSR
 Birth Certificate
 Citizenship/Immigration/Intl. Student Verification
 Immunization Certificate or Statement of Medical Exemption (copy only sent to Peel Health)
 Proof of Residence Source: ___________________________________
(e.g., property tax bill, current utility bill, real estate document, or Government of Canada issued forms)
Office Signature_______________________________________
Page 4
Middle Name:
Previous School Board: ________________________________
Personal information collected shall be used to establish and/or maintain the student’s Ontario Student Record (OSR) for the
provision of educational services and to administer health and/or medical emergency responses to the student as required. In
keeping with the requirements of the Education Act, the OSR and other information required to establish an appropriate program
for the student shall be requested from the student’s former school.
CC: Copy to be filed in the OSR
First Name:
If yes, provide an original Roman Catholic Baptismal Certificate.
If yes: Date of Baptism:
Year
If no, specify who is Catholic*:
Month
Day
 Mother
If no, receive Sacramental Preparation Letter from school
Church and City:
 Father
 Legal Guardian
*Note: An original Roman Catholic Baptismal Certificate of one of the parents/guardians must be provided at the time of registration of the student.
Medical Condition(s)/Alert:
Custody Information
Who has legal custody?
 Both parents
 Father only
 Mother only
Are there any special arrangements pertaining to access/visitation?  Yes
 Other
 No
If yes, then the most recent original Court Order to support custody must be provided (a verified copy to be stored in the OSR)
GF 008 E
Revised Oct 15
Page 1
GF 008 E
Revised Oct 15
Peel
Brampton
Lester B. Pearson Catholic
Elementary School
GF 066
NETWORK USER APPLICATION AND AGREEMENT
TO BE COMPLETED ON FIRST REGISTRATION IN DUFFERIN-PEEL
The Dufferin-Peel Catholic District School Board policy supports the use of the local and
wide area networks for electronic communication, and the Board believes this to be an
integral part of the school curriculum.
In addition to the school’s Catholic Code of Conduct and to outline in some detail the
responsibilities of the school and the Dufferin-Peel Catholic District School Board, any
student using the school network is required to adhere to the following rules:
1.
These are the “Rules of Conduct” for Electronic Networks in Dufferin-Peel schools,
including internet access.
3.
The school reserves the right to remove network access from any user who breaks
these rules.
2.
4.
5.
6.
7.
8.
9.
10.
The school reserves the right to change the rules at any time without notifying users.
(Changes to rules will be posted.)
The school does not warrant that the functions will meet any specific requirements
the student may have; nor that it will be error free or uninterrupted; nor shall it be
liable for any indirect, incidental, or consequent damages (including lost data,
information or profits) sustained or incurred in connection with the use of, operation
of, or inability to use the system. The student maintains responsibility for meeting al
personal deadlines regardless of network availability.
The student is responsible for his/her actions while using the computer.
The student will not assist in breaking these rules or be a party to others breaking
these rules.
The student must not intentionally seek information, browse, obtain copies, modify
files, or passwords belonging to others, whether at the school or elsewhere, unless
specifically authorized to do so by those individuals.
Consistent with item 7, the student will refrain from using or introducing to the
school computer environment, whether network or stand-along, files, programs, or
disks known to contain viruses. In this spirit, the student will also regularly check
his/her files and disks for viruses and endeavour to keep computing systems virus
free.
The student must not try to obtain system privileges to which he/she is not entitled.
The student will not share his/her login and password with others, nor attempt to
learn or use logins and passwords which are not his/her own.
(November 2012)
Network User Application and Agreement
11.
12.
13.
14.
15.
16.
17.
18.
-2-
The student must not exploit any gaps in security and, furthermore, must report
these gaps immediately to his/her teacher.
The student must not seek or send images, sounds, or messages which might be
considered inappropriate, obscene, abusive, offensive, harassing, illegal, or counsel to
illegal activities.
A student who receives or encounters any of the material indicated in item 12, which
makes him/her feel uncomfortable, should report it to his/her teacher immediately.
The student is responsible for determining the copyright status of any program(s) or
data used, and for respecting intellectual property rights and the laws which govern
them.
It is the student’s responsibility to back-up, save, and maintain any of his/her
information.
The student must abide by all federal, provincial and local laws.
The school reserves the right to review, edit or remove any material stored on Board
computer/network facilities.
The school will be the arbiter of what constitutes a violation of this Agreement.
Lester B. Pearson Catholic Elementary School
School: ________________________________________________________________________________________________
Name of Student (Please print): ____________________________________________________________________
I acknowledge that I have received and will abide by the Network User Application
and Agreement and that this Agreement remains in effect for the duration of the
student’s tenure in this school system.
Signature of Student: _______________________________________________________________________________
Signature of Parent/Guardian: _____________________________________________________________________
Date: ________________________________________
Lester B. Pearson Catholic Elementary School
LESTER B. PEARSON CATHOLIC ELEMENTARY SCHOOL
Patron Blessed Teresa of Calcutta
Principal: Mrs. S. Galvao
Vice Principal: Mrs. C. Pickering
Head Secretary: Mrs. C. Panetta
www.dpcdsb.org/LBPEA
Superintendent of Schools: Mrs. D. Oude-Reimerink
Parish Priests: Rev. J. Mullins
Trustee: Mr. Shawn Xaviour
MEMORANDUM
To:
From:
Re:
Date:
Parents/Guardians
S. Galvao
Local Excursions and Lunch Permission (on reverse)
2015/2016 School Year
These forms are extremely important. Please fill out this side and reverse for each
of your children.
From time to time, various classes will be involved in activities that may take us outside
the boundaries of the school. These activities include: walking excursions to local sites;
school programs offered at an alternate school site; extracurricular activities (such as
the Running Club); physical education classes (such as baseball, team practices,
walking or jogging in the park or local community).
In order for your child to take part in these activities, we need your consent. This form
will be sent home annually and kept on file by the classroom teacher. For any extended
excursions or trips away from the school involving transportation, we will send a
separate permission form.
Please fill in the consent below.
Thank you,
ACTIVITIES PERMISSION FORM 2015-2016
Teacher:
________________________________________________________
Student:
________________________________________________________
My child has permission to take part in excursion or activities at local sites.
Parent/Guardian Signature: ____________________________________________
140 Howden Blvd.
Brampton, Ont. L6S 2G1
Phone (905) 793-4861
FAX (905) 793-4497
LESTER B. PEARSON CATHOLIC ELEMENTARY SCHOOL
Patron Blessed Teresa of Calcutta
Principal: Mrs. S. Galvao
Vice Principal: Mrs. C. Pickering
Head Secretary: Mrs. C. Panetta
www.dpcdsb.org/LBPEA
Superintendent of Schools: Mrs. D. Oude-Reimerink
Parish Priests: Rev. J. Mullins
Trustee: Mr. Shawn Xaviour
MEMORANDUM
To:
From:
Re:
Date:
Parents/Guardians
S. Galvao
Lunch Routine
2015/2016 School Year
Please indicate whether or not your child stays for lunch. If there is any change in the
routine, please remember to send a note. For example, if you wish your child to come
home for lunch, please send a written note with the date or dates they are allowed to
come home; or if your child usually comes home and wishes to stay, please send a note
to your child’s teacher with the date or dates you wish them to stay. In this way, we can
more easily monitor the students and provide a safer environment.
Please fill in the form below.
Thank you for you cooperation and support.
LUNCH TIME ROUTINE FORM 2015-2016
Teacher:
________________________________________________________
Student:
________________________________________________________
My child will be going home every day for lunch.
______________________
My child will be staying at school every day for lunch.
______________________
ANY CHANGE TO THE ABOVE ROUTINE MUST BE ACCOMPANIED BY A NOTE.
Parent/Guardian Signature: ____________________________________________
140 Howden Blvd.
Brampton, Ont. L6S 2G1
Phone (905) 793-4861
FAX (905) 793-4497
GF 401
ELEMENTARY HEALTH AND PHYSICAL EDUCATION CURRICULUM –
MEDICAL INFORMATION/ELEMENT OF RISK
This form is to be completed for all students and returned to the classroom teacher.
Dear Parent(s)/Guardian(s):
Vigorous physical activity is essential for normal, healthy growth and development. Growing bones and
muscles require not only good nutrition, but also the stimulation of vigorous physical activity to increase
the strength and skills necessary for a physically active lifestyle. Active participation provides
opportunities for students to discover and trust themselves and gain the confidence necessary to play and
work cooperatively and competitively with their peers. The physical education curriculum provides
opportunities for students to experience the fitness feeling and to help them understand and make
decisions regarding personal fitness and the value of physical activity in their daily lives.
It is important that your child participate safely and comfortably in the physical education program. The
Dufferin-Peel Catholic District School Board adheres to the Ontario Physical and Health Education
Association (OPHEA) Guidelines. In your child’s best interests, we recommend the following:
a) An annual medical examination;
b) Appropriate attire for safe participation (T-shirt, shorts or track pants and running shoes). Hanging
jewelry must not be worn;
c) The wearing of an eyeglass band and/or shatterproof lens if your child wears glasses which cannot be
removed during physical education classes;
d) The wearing of sun protection for all outdoor activities;
e) Safety inspection at home of any equipment brought to school for personal use in class.
___________________
(Name of Student)
_______________
(Grade)
__________________________________
(Teacher)
I would like to inform the school about these facts pertaining to my son/daughter’s physical/medical condition related to
his/her participation in the Health and Physical Education Curriculum.
1.
What medication(s) should your son/daughter have on hand during health and physical education class? _________
2.
Does your son/daughter wear a medical alert bracelet ____ neck chain _____ or carry a medical alert card? ________
If yes, please specify what is written on it: _____________________________________________________________
3.
Any other relevant medical condition that will require modification of the program: ___________________________
________________________________________________________________________________________________
4.
Should your son/daughter sustain an injury or contact an illness requiring medical attention during the school
year, notify the classroom teacher and complete the “Request to Resume Athletic Participation Form”, as applicable.
If during the school year your son/daughter’s medical information profile changes, please notify the school.
ELEMENTS OF RISK: Educational activity programs, such as sporting events or activities, field trips and other activities,
may present various elements of risk. Incidents related to such activities may occur and cause injury through no fault of
the school board or the facility at which the activity or event is being held. Participants must assume these risks.
The following class activities including and not limited to are identified as having the potential for more serious
consequences are: alpine skiing/snowboarding, broomball (ice), cheerleading(acrobatic), field hockey, field lacrosse,
gymnastics, ice hockey, ringette (ice), swimming, wrestling, and/or field events: high jump, shot put. The safety and
well-being of students is a prime concern and attempts are made to manage, as effectively as possible, the foreseeable
risks inherent in physical activity. Please contact the school to discuss any sport specific safety concerns.
Various health/physical education activities may take students into the immediate community to participate; e.g., inclass cross country running, orienteering, soccer, softball, etc., at nearby community parks.
□
I acknowledge the element of risk information noted above for the Health and Physical Education Curriculum.
Parent/Guardian Signature:
Date:
_____________
NOTE TO STUDENT/PARENT(S)/GUARDIAN(S): The Dufferin-Peel Catholic District School Board does not provide any
accidental death, disability, dismemberment or medical expenses’ insurance on behalf of students participating in these
activities.
The Dufferin-Peel Catholic District School Board distributes Student Accident Insurance to the
Parent/Guardian/Student, annually.
□
□
I acknowledge that the Dufferin-Peel Catholic District School Board does not provide accident or life
insurance for students.
I acknowledge that I have received a copy of the student accident insurance brochure.
__________________________
__________
___________________________
(Signature of Student)
(Date)
(Signature of Parent/Guardian)
_________
(Date)
Distribution to:
____Parent/Guardian
____Classroom Teacher
MUNICIPAL FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT: Personal information on this form is collected under the legal authority of
the Education Act, R.S.O. 1990, c.E.2., as amended. This information will be used for purposes of planning and administering Physical Education
programs for students and providing health and safety services in the event of an emergency. Questions regarding the collection of personal
information are to be directed to the School Principal.
(Revised April 2013)
GF 338 A
CONSENT FORM
FOR POSTING STUDENT'S PERSONAL INFORMATION
ON A SCHOOL'S WEB-SITE
This Consent Form meets the requirements of the Municipal Freedom of Information and Protection of Privacy Act
and the Education Act for the disclosure of personal information. It provides for consent that is both informed and
voluntary, and relates to clearly identified information to be used and disclosed for clearly defined purposes.
By signing this document, I/we consent to the disclosure of personal information about
___________________________________________________ (name of student) by posting it to the Web-site of
Lester B. Pearson Catholic Elementary School
_____________________________________________________
and hence to the World-Wide Web.
(name of School)
This consent only applies to the items below that I/we have initialled:
_________
_________
_________
_________
_________
_________
_________
Photograph of _________________________________________________________________
(Name of student)
Group and class photographs including _____________________________________________
(Name of Student)
Essays written by _______________________________________(Name of Student)
Projects done by ________________________________________(Name of Student)
Awards, scholarships, prizes received by
____________________________________________(Name of Student)
Participating of _________________________________________(Name of Student)
in any extracurricular activities
(Other specific activity identified by school….please specify)
Team Sports and Clubs Photos
_______________________________________________________________________________
I/we have read and understood the Dufferin-Peel Catholic District School Board's policy on School Web-Sites. I/we
are aware that by giving this consent, I/we are permitting personal information about
____________________________________________________________________________ (name of student) to
www.dpcdsb.org/LBPEA/
be posted to the _______________________________________________________________
(School's Web-Site)
and hence to the World-Wide Web, and that if consent were withheld, this posting would not occur.
I/We further understand that this consent is valid for one year and may be withdrawn by me/us at any time, upon
written notice. In the event that consent is withdrawn, I/we understand that the information about me will be
removed from the Schools-Web-site, but understand that, in some cases, it is impossible to remove all traces of
personal information from the Internet.
(November 2012)
I/we have given this consent voluntarily.
____________________________
(place of signature; e.g. City)
on
___________________________________
(date)
a) For students under 16 years of age: signature of parent (or legal guardian).
_________________________________
Signature of Parent or Legal Guardian
_________________________________
Signature of Parent or Legal Guardian
____________________________________
Witness
____________________________________
Witness
b) For students aged 16 or 17 during the school year: signature of both the student and parents (or legal
guardian)
________________________________
Signature of Student
________________________________
Signature of Parent or Legal Guardian
________________________________
Signature of Parent or Legal Guardian
____________________________________
Witness
____________________________________
Witness
____________________________________
Witness
c) For students 18 years of age or over: signature of student
________________________________
Signature of Student
____________________________________
Witness
Notes:
Only persons having lawful custody of the student may sign this consent form as parent or legal guardian. In cases
of joint custody, it is advised that both parents provide consent.
For those situations where an individual whose consent is required is mentally incapable and a substitute decision
maker has been appointed under Ontario Law to act on his/her behalf, then the individual appointed as substitute
decision-maker should sign the consent form.
(November 2012)
STUDENT PHOTO CONSENT FORM
SCHOOL: Lester B. Pearson Catholic Elementary School
SCHOOL YEAR: 2015/2016
To: Parent(s)/Guardian(s)/Student:
Throughout the school year, the school/board will photograph and/or make video recordings of students
participating in school activities to post in school/board newsletters, Masses, school assemblies, curriculum
evening, Sacramental Celebrations, Grade 8 Graduation, School Yearbook, Achievement recognition
celebrations and promotional materials. I am also aware that Edge Imaging Photographers will be provided
with class lists containing students’ ID number, names, grades and homeroom.
Please indicate your consent for your child’s image to be used for purposes as described above, by signing
and returning this form to your child’s teacher by September 10, 2015.
To: The Dufferin-Peel Catholic District School Board
I HAVE READ AND UNDERSTAND THE INFORMATION PROVIDED ON THIS FORM. I VOLUNTARILY GIVE THE
DUFFERIN-PEEL CATHOLIC DISTRICT SCHOOL BOARD CONSENT TO PHOTOGRAPH/RECORD MY CHILD AND ITS
SUBSEQUENT USE DISCLOSURE AS DESCRIBED ABOVE. I AGREE TO RELEASE THE SCHOOL BOARD AND ITS
REPRESENTATIVES FROM ANY CLAIM OR LIABILITY THAT MAY ARISE OUT FO THE USE OR DISCLOSURE OF THE
INFORMATION.
I acknowledge that allowing my child’s participation is provided freely and voluntarily, and agree that no
remuneration, royalties or duties shall be paid nor expected. I further understand that this consent is valid for the
current school year and may be withdrawn by me at any time, upon written notice.
This Consent form meets the requirements of the Municipal Freedom of Information and Protection of Privacy
Act and the Education Act for the disclosure of personal information.
I CONSENT TO THE ABOVE:
I DO NOT CONSENT TO THE ABOVE:
_________________________________
___________________________________
_________________________________
___________________________________
Name of Student (Please Print)
Name of Parent/Guardian (Please Print)
Student Photo Consent Form
If over 16 years of age, Signature of Student
Signature of Parent/Guardian
_______________________
Date
_______________________
Date
GF 337
PERSONAL ELECTRONIC DEVICE USED WITH WI‐FI NETWORK STUDENT AGREEMENT Dufferin‐Peel Catholic District School Board policies and procedures support the use of personal electronic devices (PEDs) for educational purposes. This agreement will be signed when your child registers to attend a school within Dufferin‐Peel Catholic District School Board. In compliance with the Catholic Code of Conduct and other board policies and procedures including, but not limited to the Student Network User Application and Agreement, any student opting to use a PED while on school premises for educational purposes is required to adhere to the following: Part A. 1.
We understand that if I bring my PED to school I must follow board and school policies and procedures regarding appropriate
use of technology.
We will be a responsible digital citizen by adhering to guidelines regarding content, security, safety and ethical use through
appropriate use of technology, as outlined in the Catholic Code of Conduct and other board policies and procedures.
2.
3.
We will accurately represent myself while online and that my online interactions are reflective of our Gospel values and virtues.
4.
We understand that PEDs may be used during instructional time and in instructional space only with the expressed permission
of the classroom teacher and/or staff and only in a manner that supports the teaching‐learning process.
We understand that I may use my PED in common areas for educational purposes, as designated by the principal.
We will not share my password with others and I will respect the privacy of other people. I will not share other people’s
passwords or personal information.
We understand that upon reasonable grounds, staff reserve the right to review material viewed, created or saved on my
authorized registered PED and/or other personal electronic devices.
We understand that no school and/or board data is allowed to be stored on PEDs.
We will not use my PED in a manner that will harm the board’s system or another person's work.
We understand that if I bring my PED for use on board premises I am responsible for the safety and security of that device at all
times and the board assumes no responsibility for lost, damaged or stolen devices.
5.
6.
7.
8.
9.
10.
11.
We understand that we should not have the expectation to be able to charge our device at school.
12.
We understand that photos, videos or images of an individual/group are not permitted to be taken without expressed consent.
Expressed consent must be obtained from the individual(s) ‐ over the age of 18—or parental/guardian consent (for those under
the age of 18).
We understand the school administration will be the arbiter of what constitutes a violation of this agreement. Any failure to
comply with these guidelines may result in confiscation of my PED, discipline, a loss of PED privileges, police involvement and/or
any other consequences deemed necessary by school administration.
We agree, by virtue of access to the board’s computing and electronic communication systems, to indemnify, defend and hold
harmless the board for any suits, claims, losses, expenses or damages, including but not limited to litigation costs and legal fees,
arising from or related to the user’s access to or use of board electronic communication and computing systems, services and
facilities.
13.
14.
Part B. 1.
We understand that I am responsible to take the necessary steps to ensure my authorized PED is connected to the board wireless
network, and that the board will not be responsible for any cost incurred through the use of personal data plans.
I acknowledge that I have read, understand and agree to abide by the PERSONAL ELECTRONIC DEVICE USED WITH WI‐FI
NETWORK STUDENT AGREEMENT.
Lester B. Pearson Catholic Elementary School
School Name of Student (please print) Student Signature
Date Parent/Guardian Signature
Date Copy to the student and/or parent/guardian