You are on page 1of 8

:

______________________________ ____________________________ Female Male


SURNAME GIVEN NAME(S) ENGLISH NAME(S)

_____________________________________________________________________________
PERMANENT ADDRESS IN HOME COUNTRY

_____________________________________________________________________________

______ ______________________ ______________________________________


AREA CODE HOME TELEPHONE # EMAIL ADDRESS

_________________ ______ ___________________ __________________ _______________


DATE OF BIRTH (DD/MM/YY) AGE CITIZENSHIP FIRST LANGUAGE SECOND LANGUAGE

Mr. Ms. __________________ ___________________________ _______ ___________


SURNAME GIVEN NAME(S) AREA CODE HOME TELEPHONE #

_______ _________________________ _________________________________________


AREA CODE WORK OR CELL TELEPHONE # EMAIL ADDRESS

Mr. Ms. _______________________________ _________________________________


SURNAME GIVEN NAME(S)

_________________________________________ ___________________ ________________


STREET ADDRESS IN TORONTO OR SURROUNDING AREA CITY POSTAL CODE

_______ ___________________ _______ __________________ ______________________


AREA CODE HOME TELEPHONE # AREA CODE WORK OR CELL TELEPHONE # EMAIL ADDRESS

Beginner Low intermediate Intermediate Advanced

$3750 CAD (program, homestay and transportation between homestay and school)
$2750 CAD (program only)

E30(Stf/ConEdNonCredit/SummerESLforInterlStud/Summer2017RegForms)bg.3468
Email all refund requests to summer4internationalstudents@tdsb.on.ca.
Refund amounts as noted below are based on the date of the emailed refund request. The non-refundable
administration fee of $300 is deducted in all cases.
$3450(homestay and program) or $2450 (program only) if proof is provided by June 9, 2017 that the application
for the Visa was rejected by Citizenship and Immigration Canada.
No refund if the student withdraws after June 9, 2017.
No refund if the student violates the rules, guidelines, code of conduct and policies of the Toronto District School
Board and the school, and/or the laws of Ontario and/or Canada.

I, the undersigned, permit my child to attend and participate in all activities of the TDSB Summer 2017 ESL
Program offered by the Toronto District School Board from July 17, 2017 to August 4, 2017 and give permission to
the program staff, medical officials and homestay family (if applicable) to secure medical treatment on my behalf in
the event of an accident or illness involving my child named above, including admission to a hospital, without
liability.

Parent/ Guardian Signature: ___________________________________ Date: ______________________

IMPORTANT: PLEASE CHECK ONE OF THE BOXES BELOW, SIGN AND DATE
I hereby give consent :
No consent :
to my child being filmed, audio taped, interviewed, videotaped, photographed by the media (print and broadcast),
and employees, agents or servants of the Toronto District School Board during the period of the program.

Parent/ Guardian Signature: ___________________________________ Date: ______________________

We, undersigned, request that my son/daughter be allowed to participate in the full range of activities that will take
place during the TDSB (Toronto District School Board) Summer 2017 ESL Program from July 17 to August 4,
2017. We, undersigned, do waive and release all claims against the Toronto District School Board for any injury,
loss, damage, accident, delay or expense resulting from the applicants participation in the TDSB Summer 2017
ESL Program. We also release the Toronto District School Board and agree to indemnify them, with regard to any
financial obligation or liabilities that the applicant may cause while participating in the TDSB Summer 2017 ESL
Program. We understand that the Toronto District School Board is not responsible for any loss or injury suffered by
the applicant during periods of travel. If the applicant becomes ill or incapacitated, the Toronto District School Board
may take such actions as it considers necessary, including securing medical treatment and transporting the
applicant home at his or her own expense. We release the Toronto District School Board from all liability related to
such actions. We understand the applicants participation in the program may be terminated at the discretion of the
administrators of the TDSB Summer 2017 ESL Program without any refund of fee, and that the applicant may be
sent home at his or her own expense if he or she violates the rules, guidelines, code of conduct and policies of the
TDSB and the school, and/or the laws of Ontario and/or Canada.

I have read, accept and agree to the above Refund Policy and Participation Agreement for the TDSB Summer 2017
ESL Program for International Students.

Signature of Student: ________________________ Signature of Parent/ Guardian: _____________________

Date: ______________________________________ Date: ________________________________________

E30(Stf/ConEdNonCredit/SummerESLforInterlStud/Summer2017RegForms)bg.3468
Students name ________________________________________________ Name of Reason Dosage Method of
Medication Administration
SURNAME GIVEN NAME / ENGLISH NAME
_________________ _____________ _______ ________________

Date of birth
_________________ _____________ _______ ________________
DD / MM / YY Female Male
_________________ _____________ _______ ________________
Name: TDSB International Health Insurance Plan
Ingle International (www.inglestudents.com/tdsb) _________________ _____________ _______ ________________
Other Medical and Accident Insurance
Insurance numbers: ____________________________________________ DIETARY RESTRICTIONS:
List any foods that should be avoided for medical, dietary or
religious reasons. Explain the severity of the condition and
PLEASE CHECK ANY OF THE FOLLOWING HEALTH any precautions required.
OR MEDICAL CONDITIONS:
_____________________________________________________
Ear/Throat Infections Urinary Infections
. _____________________________________________________
Epilepsy Fainting Spells Sleep Walking

Diabetes Migraine Headaches LIMITATIONS/PARTICIPATION:


Please explain any limitations or other concerns which might
Hemophilia Digestive Upsets Nosebleeds
affect the student's participation in the program.
Medical Alert for : ____________________________________________
_____________________________________________________

_____________________________________________________
OTHER CONDITION(S):________________________
Please give details of condition and treatment CONSENT OF PARENT:
Details: ________________________________________________ I/We understand that in the event of a medical emergency,
medical and TDSB staff can authorize emergency care.
_________________________________________________________ This would only apply in the event of an emergency and if
Summer ESL program staff, and/or Homestay Family
Treatment: ________________________________________________ (if applicable) have been unable to contact the Parent(s)
______________________________________________________ /Guardians(s).

Allergies\Asthma Rate of Severity Reaction/Treatment SIGNATURE OF PARENT/GUARDIAN:


Mild 1 2 3 4Life Threatening

Does student have an EpiPen Yes No

Expiration date of EpiPen _______________


Asthma Inhaler Yes No
DATE:

If allergy or asthma is life threatening, a doctor's signature verifying


DD / MM / YY
student is able to physically travel and attend our program is required.

MEDICATION:
Is student self- medicating? Yes No
Tetanus shot within the last ten years: Yes No

E30(Stf/ConEdNonCredit/SummerESLforInterlStud/Summer2017RegForms)bg.3468

E30(Stf/ConEdNonCredit/SummerESLforInterlStud/Summer2017RegForms)bg.3468

E30(Stf/ConEdNonCredit/SummerESLforInterlStud/Summer2017RegForms)bg.3468
E30(Stf/ConEdNonCredit/SummerESLforInterlStud/Summer2017RegForms)bg.3468
Student Media Release Consent Form
Summer 2017 ESL Program for International Students: July 17-August 4

Please ensure one box is checked for Part 1 and one box is checked for Part 2 of this form

Part 1 Events
I, _____________________________________________________, hereby agree and give my permission for the
(Name of parent/guardian if student is a minor, under the age of 18)

Toronto District School Board (TDSB) and/or partners to record, film, photograph, audiotape or videotape my/my
childs name, image, student work, and performance (hereinafter collectively referred to as Works) and to
display, publish or distribute these Works for the purpose of publishing, posting on the TDSB website, posting in
schools, posting on social media sites and/or for broadcasting on television or radio as determined by the TDSB.

I hereby waive any right to approve the use of these Works now or in the future, whether the use is known to me or
unknown, and I waive any right to any royalties related to the use of these Works.

I understand that the Works may appear in electronic form on the internet or in other publications outside of the
TDSBs control. I agree that I will not hold the TDSB responsible for any harm that may arise from such
unauthorized reproduction.

Please mark this box if you AGREE that your child may participate in recorded
TDSB/school events and TDSB hosted events as described above. (See Part 2 below)

Please mark this box if you DO NOT WISH your child to participate in recorded
TDSB/school events and TDSB hosted events.

Part 2 Media Specific


I also understand that external media organizations may attend school events. I give permission for my/my childs
name, image, student work, and performance to be photographed, filmed, audio-taped or videotaped for the
purpose of being published and/or broadcast on-line, on television or radio.

Please mark this box if you AGREE that your child may participate in media events
that may be published or broadcast by organizations external to the Toronto District
School Board.

Please mark this box if you DO NOT WISH your child to be photographed, filmed,
audio-taped or videotaped at media events.

I have read this Student Media Release Consent Form and I fully understand the contents and meaning of this
release. I understand that I am free to contact the Principal with any questions regarding this release.

Students Name: __________________________________________________________

School/Program:

Parents/Guardians Name:

Parents/Guardians Signature:

Date:

E30(Stf/ConEdNonCredit/SummerESLforInterlStud/Summer2017RegForms)bg.3468
E30(Stf/ConEdNonCredit/SummerESLforInterlStud/Summer2017RegForms)bg.3468

You might also like