HomeMy WebLinkAboutOCDSB 938 B Request for Supervised Alternative LearningPR.508.CUR: Appendix B
REQUEST FOR SUPERVISED ALTERNATIVE LEARNING
Request made by:
Student (16 or 17 years of age who has withdrawn from parental control)
Parent/Guardian
Principal (Principal must inform, and request input from, the parent/guardian before submitting application to committee.)
Student information
Grade: OEN: Language spoken:
Last name: Gender: Male Home telephone:
First name: Female Cellular telephone:
Middle name: Another Gender
Identity
E-mail:
Prefer not to Specify
City/Town: Postal code:
Date of Birth:
Address:
Parent/Guardian information
Name:
Address (if different from student’s):
School last attended by student
Address:
Telephone:
Last day of attendance:
Reason for request Proposed activities
Credit course(s)
Employment
Non-credit courses (e.g., life skills)
Certification and training
Counselling
Volunteer opportunity
Other:
PARENT/GUARDIAN AUTHORIZATION RE: CONSENT TO RELEASE
I/we give consent for school staff to use and share the information provided in this form as required to attend to the education, health
and safety of myself/my child.
The information provided on this form is collected pursuant to the Board’s education responsibilities as set out in the Education Act
and its regulations. This information is protected under the Municipal Freedom of Information and Protection of Privacy Act
(MFIPPA) and will be utilized only for the purpose of managing student learning and well-being. Access to this information will be
limited to those who have an administrative need, to the student to whom the information relates and the parent(s)/guardian (s) of a
student who is under 18 years of age. Any questions with respect to this information should be directed to the school principal.
_____________________________
Student
____________________________
Parent/Guardian
_____________________________
Principal
_____________________________
Date
_____________________________
Date
_____________________________
Date
Fax:
Telephone (day):
OCDSB 938 (April 2018)