Student HealthRecord Registration

*Required

Parent Information

Parent/User ID*:

Password*:

Verify Password*:

Important! User IDs and Passwords must be at least 6 characters long and contain at least 1 number and 1 letter. More info on creating a valid User ID and Password

Secret Question*:

If you forget your User ID/password, this will be one way to retrieve it.

Secret Answer*:

Parent 1/Legal Guardian Name*:

Parent 1 DOB*:

MM/DD/YYYY

Parent 2 Name:

Parent 2 DOB:

MM/DD/YYYY

* I accept the Privacy Policy.

Student Information

Student Name*:

First Name

Middle Name

Last Name

Suffix
(Jr., Sr., etc.)

Student DOB*:

MM/DD/YYYY

Please fill in Student home mailing address.

Student Address 1:

Student Address 2:

Student City:

Student Province:

Student Country:

Student Postal Code:

Parent Contact E-mail*:

Ontario Education Number (OEN) or student id Number:

Student email:

I understand that my E-mail will only be used for important network messages. Your E-mail will never be shared.

Student Gender*:

Male Female

School Board Name:

School Name:

Current Grade:

Please fill in your Family Physicians information.

Physician Name:

Physician Phone:

###-###-####

Physician Address:

Address, City, Prov.

Provincial Health Plan:

Provincial Health Plan Number:

One contact phone number is required.

Parent 1 Day Phone*:

###-###-####

Parent 1 Evening Phone*:

###-###-####

Parent 2 Day Phone:

###-###-####

Parent 2 Evening Phone:

###-###-####

Parental Consent is required.

Important Note:
We understand that information about you and your child's health is personal and we are committed to protecting the privacy of that information. Because of that commitment, we require your consent below to allow the use and disclosure of this information by the School and School Board. This information will only be used in the case of a school emergency where such information may be vital to the health of the student.

Authorization:
I confirm that I am the parent or legal guardian of the child whose information I am providing and I understand that by checking the box below I am giving my consent to the School Board and School Administrator to access this information in case of an emergency at school or a school event, field trip or other school function where the continued good health of the student may be at risk.

* I agree and give my consent.