HomeMy WebLinkAboutOCDSB 191 Permission Form Referral to FNMI-SSROCDSB 191 PERMISSION FORM
Student Name: Parent/Guardian Name:
D.O.B: Telephone Number:
Home Address: Parent/ Guardian Name:
Gender: Telephone Number:
Student ID: Grade/Program:
OEN #: Principal Name:
We would like to refer you/your child to the First Nations, Métis & Inuit (FNMI) Student Support/
Re-Engagement Coordinator, a staff member of the Ottawa-Carleton District School Board, for
the following reasons:
The First Nations, Métis & Inuit Student Support/Re-Engagement Coordinator at the Ottawa-
Carleton District School Board may offer support including (but not limited to): one-to-one
sessions with students (K-12) for cultural support at school and/or at home, mentorship, cultural
programming, referrals to appropriate programs/services in the community, talking circles,
transition supports (i.e. entry, elementary to secondary, secondary to post-secondary, moving to
a different community), facilitate involvement by parents/guardians of FNMI students and
students who identify as FNMI regarding academic success, re-engagement of students who
have withdrawn/at- risk of withdrawing from school, and liaising with teachers and support staff
at school. Referrals to programs/services may include professional staff from the following
organizations: OCDSB, Ottawa Inuit Children’s Centre, Wabano Centre for Aboriginal Health,
Odawa Native Friendship Centre, Minwaashin Lodge, Tungasuvvingat Inuit and Métis Nation of
Ontario. Support from the FNMI Student Support/Re-Engagement Coordinator may require a
review of the student’s Ontario Student Record (OSR) after meeting with the parent/guardian or
youth (if 18 or older) and permission form has been signed.
This information will be protected, pursuant to the MUNICIPAL FREEDOM OF INFORMATION
AND PROTECTION OF PRIVACY ACT, and will not be released to any outside person or
agency without prior written authorization.
Distribution:
Original
Copies
- OSR
- FNMI Student Support
- Parent/Guardian/Student
(If 18 or older)
OCDSB 191 Curriculum (November 2016) Page 1
School Year
If you agree and consent to the involvement of the Ottawa-Carleton District School Board staff
as noted above, please sign below. This permission form will be placed in the above-named
student's OSR and, unless revoked in writing earlier, shall expire at the end of the current
academic year.
Date Principal
Date FNMI Student Support/Re-Engagement Coordinator
Date Parent/Guardian/Student (If 18 or older)
Distribution:
Original
Copies
- OSR
- FNMI Student Support
- Parent/Guardian/Student
(If 18 or older)
OCDSB 191 Curriculum (November 2016) Page 2
Personal information on this form is collected under the authority of the Education Act and will only be used
to plan an appropriate program for the student. The information on this form is confidential and access will
be limited to those employees who have an administrative need, the student, and parent(s)/guardian(s) of a
student who is under eighteen years of age. If you wish to review the information on this form, please contact
the school principal.