Student's Information Has the student ever attended school? Address of last school attended Is this student a subject of a court or custody order? Please provide a copy of the court order to the school. If you have a digital copy, you can upload it below. Language spoken at home? Language first spoken by student? Language most often spoken by student? Has the student ever received services as an Exceptional Student? If yes, please select the student's exceptionality Other? Parent/Guardian's Information Does the student reside at this address? Relationship to student? Home Phone Mobile Phone Work Phone Second Parent/Guardian's Information Home Phone Mobile Phone Work Phone Does the student reside at this address? Relationship to student? Person with whom the student lives with if not the parent/guardian * Relationship to student? Phone Work Phone Emergency Contact
Please provide up to 3 alternative contact persons in case of emergency. Emergency contacts must be over the age of 18 and capable of caring for the child if you are unavailable.
Emergency Contact's Name * Emergency Contact's Phone Number Emergency Contact's relationship to the child * Parent or legal guardian Parent or legal guardian Grandparent Sibling (over 18 years old) Extended family Other 2nd Emergency Contact's Name * Emergency Contact's Phone Number Emergency Contact's relationship to the child * Parent or legal guardian Parent or legal guardian Grandparent Sibling (over 18 years old) Extended family Other 3rd Emergency Contact's Name * Emergency Contact's Phone Number Emergency Contact's relationship to the child * Parent or legal guardian Parent or legal guardian Grandparent Sibling (over 18 years old) Extended family Other Student's Doctor/Clinic Phone Hospital of Choice Does the student have any special medical conditions/allergies/procedures of which we should be aware of? Please list them below. Electronic Communication System I hereby understand that students of LinaBean Academy will be granted access to the system's electronic communication system which includes access to the Internet and World Wide Web. This access is a privilege, not a right. The system may suspend or revoke a system's user access upon violation of system policy and/or administrative regulations regarding acceptable use or upon written parental request to the campus principal. I further understand that the school will publish my child's individual photograph, video and or last name without my written permission Medical Information (Optional) You do not have to provide information on medical concerns but, the information could be crucial to the wellbeing of the student. Are there any serious medical conditions about which you wish the school to be aware? Please indicate below Other? Please specify Student's Alberta Health Care Number All of the information given on this form is correct WAIVER AND RELEASE FORM LIABILITY RELEASE AND PARENTAL CONSENT FORM In consideration of the acceptance of my application for the above program, I hereby unconditionally wave, release, and discharge any and all legal/non-legal claims for damages for personal injury, property damages or which may hereafter occur to me as a result of my participation and said and any any event. This release is intended to discharge in advance LinBean Academy INC. (The Academy), it's officials, officers, employees, volunteers and agents from liability, even though the liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities (including public transportation, volunteer transportation and pedestrian field trips) involve an element of risk or danger of accidents, and knowing these risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees. Complete if applicant/student/child(ren) is under 18 I give permission for my student to participate in the above activities, and I execute the above liability release on their behalf I hereby give my consent to have the above applicant treated by emergency medical personnel, a physician, or surgeon, in case of sudden illness or injury while participating in the above activity. It is understood that the Academy will provide no medical insurance for such treatment, and that the cost thereof will be at my expense. I have read and understood the foregoing registration liability release and parental consent form, and agree to all of its terms and conditions. Executed by: