NOTE: This form is to be completed by all students entering R.C.I.

  Please return this form to the office by September 5, 2003.

REGISTRATION FORM

Registering Teacher:      _________________________          Locker No.   ______  

Name of student in full, circle used name:

_________________________                  ________________________________          

                Surname                                                                 Christian Name(s)

Age as of September 30th: _______     Birthday:  ______   _____  _____  Grade _______ 

Christian (first) names of both parents/guardians. Custody:       Joint       Mother       Father

Father ____________________________                    Mother  _______________________  

P.O. Address  ___________________________          Town        ______________________   

                                       Box No.

                                                                                          ________   /    ______  / ________          

                                                                                             Section        Township        Range           

Telephone Number: _______________        Last School Attended: ______________________        

Cellular Number:     _____________               Bus Driver: ____________________________

Billet in case of storm:       _________________________                 __________________      

                                                         Name                                                       Phone No.

R.C.I. EXTRA CURRICULAR ACTIVITIES

PERMISSION FORM for    _________________________________          2003-04 School Year

The teachers on extra curricular trips require a brief medical fact sheet to take along when the team/group leaves the school.

Please fill in the following form and return to the school. Thank you for your cooperation.

I/We, as parent(s) of    ___________________________ will allow my/our child to participate in

extra curricular activities during or after school hours.

My child's Manitoba Family Medical number is    _____________________________         

PHIN number     _____________    

My child's doctor is ___________________________________   

in ________________________________  ,   ________________ 

                (town, city)                                             (province)                              

Telephone:   _____________________________

MEDICAL INFORMATION REQUEST

If your child has any allergies or other medical/physical problems (vision/hearing) that we should be aware of, please list them below. All students enrolled in Fort La Bosse School Division schools for the first time must forward proof of measles immunization.

NOTE: A nil response is required if your son/daughter is fortunate enough to be without medical or physical handicaps.

List of allergies, handicaps, medical problems: ____________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________                                                                                                                                                                

 Must wear glasses ___________________   Yes / No

         ______________________                                     

             Parent/Guardian Signature                                      

The person to contact in case of emergency is: _________________ /______________                         

                                                                                                                phone

or _____________________/_________________.

                                                    phone

I give authorization to proceed with medical attention in case of a medical emergency.

Signed  _________________________________      Dated __________________                               

RELEASE 

 I acknowledge that school staff members or other Division employees may be called upon to give voluntary first aid or medical assistance to my child or transport my child home or to a medical facility for treatment, in the event of illness, accident or injury.

  I also acknowledge that such staff members or employees are not trained medical professionals, and that such assistance is given voluntarily for the benefit and well-being of my child.

In consideration of such voluntary assistance, I release and discharge the Fort La Bosse School Division No. 41, its staff, employees, officers, trustees and agents from all liability to me and/or my child from the giving of such first aid or medical assistance, or the transporting of my child home or to a medical facility for treatment.

Dated this   _________ day of  ________________ , ________     .

                                                                                        Year

_____________________                _______________________

       Student Signature                                    Parent Signature

NOTE: The information forwarded on this form will remain on file during the 2003-04 school year. The onus is upon you, the parent, to advise school administrative personnel of any change in the information forwarded on these two pages.

RURAL STUDENT REQUEST FOR NOON HOUR PRIVILEGE

I HEREBY REQUEST PERMISSION FOR MY SON/DAUGHTER TO BE ALLOWED

TO BE ABSENT FROM SCHOOL AS FOLLOWS: PLEASE INCLUDE THE NAMES

OF ALL FAMILY MEMBERS FOR WHOM YOU ARE REQUESTING THIS

PRIVILEGE ON THE LINE BELOW.

STUDENT(S) ___________________________________________________________

TIMES OF ABSENCE: DURING THE NOON HOUR PERIOD ON SCHOOL DAYS.

I UNDERSTAND THAT THERE IS NO SUPERVISION BY SCHOOL STAFF

DURING THE TIME OF THE ABSENCE.

I RELEASE FORT LA BOSSE SCHOOL DIVISION NO. 41, AND ITS STAFF AND

AGENTS, FROM ALL LIABILITY FOR ANY INJURY, ACCIDENT, OR MISHAP

WHICH MAY OCCUR DURING THE REQUESTED ABSENCE. THIS REQUEST

WILL REMAIN ON FILE AND IN FORCE DURING THE 2003-04 SCHOOL YEAR

OR UNTIL SUCH TIME AS IT IS EITHER REVOKED BY A PARENT/GUARDIAN

OR SUSPENDED BY A SCHOOL STAFF MEMBER.

DATE: __________________________________

            ____________________________________

              STUDENT SIGNATURE

                                                 _______________________________

                                                      PARENT/GUARDIAN SIGNATURE