VCH Immunization (Vaccination) Information For School Form          

Proof of Residence in the City of Vancouver [please submit one of the following]:

• A current property tax statement or purchased agreement [with subject removal and deposit receipt], and a recent bill.

• A current long‐term rental or lease agreement. If NOT CURRENT, and a recent bill.

Child’s Original Birth Certificate and English translated version [ ideally showing parents’ names] 

Proof of Status in Canada [please submit one of the following for both parents and child]:

•Permanent Residence Card or the Confirmation of Permanent Residence document and passport.• Work Permit and Passport‐‐with parent's [minimum of one year] current full-time employment letter.• Study Permit and Passport‐‐with parent's program admission letter and payment receipt.• Refugee Claimant Document.• Diplomatic Card or Passport.• Canadian Passport or Citizenship Card or Birth Certificate.• Status Identification Card.

  Child’s School Report Cards [in English] • Elementary ‐ Two most recent years of report cards.• Secondary ‐ All report cards from Grade 7 [age 13 to present].• Any Individual Education Plan [IEP], Psycho‐Education Reports, or Medical Report.

Vancouver School Board  www.vsb.bc.ca 

NWC [2020 - 06]

Immunization Records [if available, no need to translate] and any other health information [e.g. medical alerts,

in English].  

Other relevant documentation involving Guardianship: a Court Order [Divorce/Separation] or a Parent

Consent Letter.

APPLICATION CHECKLIST:

Newcomer Welcome Centre (NWC) [East-Wing of Moberly Elementary] 1000 East 59th Avenue, Vancouver, BC V5X 1Y7 Tel: 604-713-5999 Fax: 604-713-5998

Online Registration Form Please v is i t our website [www.vsb.bc.ca/site/nwc/registration/Pages/Online-Registration]. You are using this online form only if you and your child are currently residing in Vancouver.

*Note: Catchment school may ask for additional identification as proof of residency.

**Please note: For documents which are not in English/French, please have them translated in English by a certified translator.

For Office Use Only

Student Name:______________________________________________________________Birthdate:_________________ [Legal Last Name], [Legal First Name] [Called Name] [dd/mm/yyyy]

Permanent Address:_____________________________________________________________________________________[House Number and Street Name] [City] [Province] [Postal Code]

English speaking contact name:______________________________________ Phone:_______________________ [Emergency Contact First Name and Last Name] [Emergency Contact Phone]

Most recent school attended:__________________________________________________________________________ [School Name] [City] [Province/State] [Country]

Has your child studied in a school in BC? No If Yes: ____________________________________

Has your child been in a Vancouver public school? No [School Name]

If Yes: ______________________[School Name]

Applying for: Special Needs ?

For Sept________________________________________________________________________________________FOR OFFICE USE ONLY:

September Catchment School: ___________________________________________________ Gr: _________ Is student present? Yes No Special Needs Consideration? Yes No

Student’s Documents:

Canadian Passpt/Birth Cert./ Permanent Residence Card Landing Paper and Passport Birth Certificate [Translation] Previous School Report Card [Translation]

Immunization Record Name Change Document Other: _______________________

Parent’s Documents:

Canadian Passport/Birth Cert./ Status Card

PRCard/Immigration Document and Passport

Diplomat Card/Passport Work/Study Permit, with an employment letter or admin. letter and receipt paid

Refugee Immigrant or Claimant

If parent separated or divorced:

Custody Order/Consent letter

Other: _______________________

Proof of Address:

Current Property Tax Statement

Purchasing Agreement with a Subject Removal & Depos. Rec.

Long-term Tenancy Agreement /Hydro/Phone/Cable Bill [if necessary]

Other: _________________________

Registration Completion Date: Assessment Date:

Note(s):

____________________ _____________________

NWC [2020-06]

[Someone who IS NOT the parent]

A parent/legal guardian is NOW in Vancouver, BC The student is NOW in Vancouver , BC

PLEASE COMPLETE THE FOLLOWING:

Please check to confirm:

Does student have special needs? Yes No

Specify:

STUDENT INFORMATION

Gender: (Check one) Male Female

Legal Last Name:

Legal First Name:

Legal Middle Name:

Usual Last Name:

Usual First Name:

Birth Date:

Proof of Age [Check one and attach]Birth Certificate Certificate of Citizenship Court Order Passport Other

STUDENT CITIZENSHIP INFORMATION Province/Country of Birth: Citizen of What Country:If not a Canadian Citizen. Date of entry into Canada:

Language at Home: Language Often Spoken: First Language: Interpreter Required? Yes No

Citizenship Status: FOR OFFICE USE ONLYInternational Funding Eligibility Yes NoInternational Funding Not Eligible Yes NoOut of Province Canadian Not Eligible Yes NoPermanent Resident/Landed Immigrant Yes NoRefugee Yes NoStudy Permit #:Permit Expiry Date:

PARENT/GUARDIAN INFORMATION [First Parent]

Living with student Yes No Emergency Contact Yes No Speaks English Yes No

No Willing to Volunteer? Yes Who has legal custody? Legal Last Name: Legal First Name:Home Telephone #: E-mail Address:VISA/Wk/Stdy Permit-UCI #: Business Phone # if available at work:

[Continue on next page]

VANCOUVER SCHOOL BOARD

STUDENT APPLICATION FORM Newcomer Welcome Centre

(NWC)

Address:

City:

Province: Postal Code:

Check if unlisted: Check if unlisted:

ParentPhone#:

ParentMobile#:

Proof of Address Attached

Catchment School:

Date Application Received:

SIS Pupil #:

PEN:

Grade: Home Room:

Program:

School Currently Attending:

Relation to student: [Check one]Mother Father GrandparentGuardian Aunt UncleHomestay Other Family Services

Same as Student’s Address Yes NoIf not living with student provide address:

Mobile Phone #:

NWC [2020-06]

Student attended a Strong Start Centre? Yes NoIf yes, name of school:

Citizenship Information [Check one and attach] Canada Immigration Record Immigration Canada Permit Immigration Canada VISA Passport Permanent Resident Card Permanent Resident Form

Aboriginal AncestryDo you have Aboriginal Ancestry?

Yes No

FOR OFFICE USE ONLY

[dd/mm/yyyy]

[dd/mm/yyyy]

PARENT/GUARDIAN INFORMATION [Second Parent]

Living with student Yes NoEmergency Contact Yes NoSpeaks English Yes NoWilling to Volunteer Yes NoWho has legal custody?Legal Last Name:Legal First Name:Home Telephone #:E-mail Address:VISA/Wk/Stdy Permit-UCI #:SIBLING INFORMATION (School age siblings 5-18 yrs.)

Legal Last Name, Legal First Name 1. Name: Male Female2. Name: Male Female3. Name: Male Female

EMERGENCY CONTACT INFORMATION: OTHER THAN PARENT

Legal Last Name: Legal First Name:Relationship: Address:Does this person speak English? Yes No Work Phone #:Home Phone #: Mobile Phone #:

EMERGENCY CONTACT: OUT OF PROVINCE/COUNTRY[IF YOU DO NOT HAVE A LOCAL CONTACT, call in the event of a natural disaster]

Legal Last Name: Legal First Name:Does this person speak English? Yes NoLegal relationship to student: Work Phone #:Home Phone #: Mobile Phone #:

STUDENT MEDICAL HEALTH INFORMATION

Doctor Name: Dentist Name: Care Card #:

NoIs an Immunization Record attached? Yes No No

Phone #: Phone #: Allergies and Health Conditions [Check one] Allergies/Conditions Yes If yes, What?Life Threatening? Yes What?

The information on this form is collected under the authority of the School Act, Sections 13 and 79. The information provided will be used for educational programs and administrative purposes, and when required may be provided to health services, social services or support ser-vices as outlined in Section 79(2) of the School Act. The information collected on this form will be protected consistent with the Freedom of Information and Protection of Privacy Act. If you have any questions about the information recorded on this form, please contact the School Administrator.

I certify that the above information is correct and valid as of this date. I understand that the provision of false information may

lead to my child no longer being able to attend the assigned school.

Parent / Guardian Signature: Date: Verified by:

Administrator’s Signature: Date:

Relation to student: [Check one]Mother Father GrandparentGuardian Aunt UncleHomestay Other Family Services

Same as Student’s Address Yes NoIf not living with student provide address:

Mobile Phone #:Business Phone # if available at work:

Birth Date: Birth Date: Birth Date:

NWC [2020 - 06]

[dd/mm/yyyy]

[dd/mm/yyyy]

[dd/mm/yyyy]

Parent Declaration I am a parent or legal guardian [to become a legal guardian requires a B.C. Family Court Order] for this child. I understand that

my child is entitled to receive a funded education from the Province of British Columbia [governed by the Ministry of

Education] on the condition that I reside [i.e. primary residence] in the province of British Columbia throughout my child’s

educational life. I understand that at least one parent [or legal guardian] has to remain in residence in British Columbia in

order for my child to qualify for a free public education. If not, I will be charged retroactively for my child’s tuition fees

according to the current rate for International Students.

I, the undersigned, do declare that I am (please ):

a Canadian citizen

a Landed Immigrant / Permanent Resident

lawfully admitted into Canada with one of the following categories of entry:

landed immigrant refugee

refugee claimant

study permit for one or more years

work permit for one or more years

diplomatic admission [carrying out official duties as a diplomatic or consular official]

Other - Document description noted below: This category must be cleared with Immigration Canada

I, the undersigned, will be permanently residing in B.C. WITH my child. I will not be residing elsewhere and will not be taking extended trips during the school year. Currently my home address is:

[House Number and Street Name] [City] [Province] [Postal Code]

I am aware that by making a false statement, I may be liable for my child’s educational costs at the current rate of

International Student fees*. Such costs will be charged from the date of this document. All applicable fees, fines and charges

will be at my expense. * (Please visit this site for current fee schedules: https://www.vsb.bc.ca/site/International-Education/Apply/

admissions/Pages/default.aspx)

Student’s Legal Name (please print in English) :

Parent’s/ Legal Guardian’s Legal Name:

Signature of Parent/Legal Guardian :

Date: NWC Staff: [dd/mm/yyyy] (Witness)

Translated form is provided for the easy reference of applicants.The Vancouver School Board always follows the policies

and definitions as stated in the English Version of this form.

PLEASE READ CAREFULLY

NWC [2020-06]

[Legal Last Name], [Legal First Name]

[Legal Last Name], [Legal First Name]

[Parent/Legal Guardian's Signature]

Newcomer Welcome Centre[East-Wing of Moberly Elementary] 1000 East 59th Avenue, Vancouver, BC V5X 1Y7 Tel: 604-713-5999 Fax: 604-713-5998

家長聲明

本人是學生家長或法定監護人 ( 要成為法定監護人, 請附上一份B.C.省法庭頒發給你的法定監護人委任令) 。 本人明白B.C.

省政府 ( 教育廳 ) 撥款支付我孩子的教育經費是完全基於我在我孩子教育生活期間, 我會永久 (主要) 居住於B.C. 省內。

本人明白必須至少有其中一位家長 (或法定監護人) 居留在B.C. 省內, 孩子才可獲資格接受免費教育。 否則, 本人會支付

現時國際學生課程部所定的學費。

本人 (下列簽署者) 認真並莊嚴地發誓是 (請 )

加拿大公民

加拿大永久居民

持有下列證件合法進入加拿大境內:

已被接獲申報難民紙

正在申報難民紙

為期一年或以上的學生簽証

為期一年或以上的工作簽証

外交官員或領事官員證件

其它證件 (請註明): (此項必須通過加拿大移民局批核)

本人 (下列簽署者 ) 將會永久與我的孩子居住於B.C.省內。 本人不會居住於其他地方, 亦不會在孩子上學期間有長期出國

行程。 本人現在的住址是:

本人知道若提供假供詞, 本人會負責我孩子所有的教育經費, 而費用會按照國際學生課程部所定的學費* 收取, 並會在此表

格所填的日期開始計算。所有有關的費用及罰款亦會由本人負責支付。

* (請到此綱址 https://www.vsb.bc.ca/site/International-Education/Apply/admissions/Pages/default.aspx 查詢國際學生課程部所定的學費詳情。)

孩子法定名字 (請用英文填寫) :

家長 / 法定監護人名字 (請用英文填寫) :

家長 / 法定監護人簽署 :

日期 : NWC 職員:

(見證 )

本局翻譯的表格只為提供申請人閱讀時的方便。 温哥華教育局以英文版本表格上的守則和定義作準。

請仔細閱讀

NWC [2020-06]

Newcomer Welcome Centre[East-Wing of Moberly Elementary] 1000 East 59th Avenue, Vancouver, BC V5X 1Y7 Tel: 604-713-5999 Fax: 604-713-5998

[dd/mm/yyyy]

Protected “B”, when completed

* Most recent date 1= Eight or ten digit number (UCI: ####-#### format) on immigration documents PR= Permanent Resident P=Parent C=Child

SWIS Service Form (One per Family)

Parents/Guardians: Please complete this form to receive FREE information and referral on government benefits, community and

school resources, settlement counselling, and other services provided by Settlement Workers in Schools (SWIS).

Date of Registration: _______________

Legal Last Name Legal First Name Gender Date of Birth dd/mm/yyyy

ImmigrationClient ID Number(UCI)*1

Parent 1

Parent 2

Child 1

Child 2

Child 3

Child 4

Child 5

Address

Mobile Phone# Home Phone#

Preferred Official Language of Service

English French No Preference

Date of arrival in Canada*

(dd/mm/yyyy)

Immigration Country of

Origin

Language Spoken at

Home

Email

P1

P2 Same as above Same as aboveSame as above

C1

C2

C3

C4

C5

Vancouver School BoardSCHOOL District # 39

Settlement Workers in Schools (SWIS) Program

M F

M F

M F

M F

M F

M F

M F

NWC [2020-06]

City: Postal Code:

Family Members

Same as above

Same as above

Same as above

Same as above

Same as above

Same as above

Same as above

Same as above

Same as above

Same as above

Same as above

Same as above

Same as above

Same as above

Same as above

[dd/mm/yyyy]

Family Members

Status in Canada

(Please select one)Category

(Please select one)

P1:

P2:

Immigration Sub-Category

(For Office Use Only)

C:

Consent Form

The personal information that you provide on this form will be treated as confidential. It will be used to assess your needs and your eligibility for the program. Your personal information may be shared with the funder (the Immigration, Refugees and Citizenship Canada), and the Vancouver Board of Education for the purpose of contract monitoring, auditing, and/or research purposes, such as program evaluation or client satisfaction surveys.

The information collected on this form is governed by two authorities:

a) The Immigration and Refugee Protection Act. Through the funded service provider, the Settlement Workersin Schools (SWIS) program of the Vancouver Board of Education, the information provided will be used forthe purposes of assessing the settlement needs of the newcomer students and their family members inorder to plan support actions for the newcomer families.http://www.cic.gc.ca/english/resources/publications/gather-info.asp

b) The BC School Act, Sections 13 and 79. The information provided will be used for educational programs andadministrative purposes, and when required, may be provided to health services, social services or supportservices as outlined in Section 79 (2) of the School Act.

The personal information collected is protected by the Canadian Federal Privacy Act, the Personal Information Protection and Electronic Document Act (PIPEDA) as well as the British Columbia’s Freedom of Information and Protection of Privacy Act (FOIPPA), which governs the collection, use and disclosure of personal information by public bodies, as well as recognizes the right of individuals to protect their personal information.

By verbally agreeing to or signing this form, you have given permission for the Vancouver Board of Education to disclose the personal information we collect to the government employees or designates for the purposes noted above.

Parent 1 Parent 2 Name:

Signature:

Date: [dd/mm/yyyy] [dd/mm/yyyy]

□ Verbal consent provided over the phone □ Verbal consent provided in person

For Office Use Only:

Home School: Student Assessment Date & Time:

dd/mm/yyyy hh/mm

Case Manager: Family ID:

SWIS #3: Note:

Assigned Intake Worker:

Intake Provided by:

Intake Date: Date: Taken By:

NWC [2020-06]