STUDENT REGISTRATION FORM
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1 STUDENT REGISTRATION FORM Please forward registration form to: Peel District School Board Peel Academy for International Students 5650 Hurontario Street Mississauga, ON, Canada L5R 1C6 Tel: ex Fax: School assignment: Grade: Class: Date: Copy sent to school: Date: Study permit: yes/no If yes, expiry date: FOR OFFICE USE ONLY Renewal?: yes/no If no, explain: Please print the following information in English. STUDENT INFORMATION Last Name First Name English Name Gender (M/F) Citizenship Country of Birth Date of Birth (Year/Month/Day) Age First Language Second Language Address Home Address in Peel (if available) City, Province Postal Code CURRENT SCHOOL INFORMATION Current School Name Last Grade Completed Current School City Current School Country PARENT/GUARDIAN INFORMATION PARENT/GUARDIAN #1 Last Name First Name Address
2 Relationship PARENT/GUARDIAN #2 Last Name First Name Address Relationship PARENT/GUARDIAN CONTACT INFORMATION Permanent Home Country Address City Province/State Zip/Postal Code Home Phone Number Cell Phone Number Work Phone Number CUSTODIAN INFORMATION Homestay in Canada Last Name First Name English Name Gender (M/F) Status in Canada: Canadian Citizen Permanent Resident Country of Birth First Language Second Language Address Home Address City, Province Postal Code Home Phone Number Cell Phone Number Work Phone Number EMERGENCY CONTACT INFORMATION (other than parent/guardian) CONTACT #1 Last Name First Name Address Relationship Home Phone Number Cell Phone Number Work Phone Number CONTACT #2
3 Last Name First Name Address Relationship Home Phone Number Cell Phone Number Work Phone Number PROGRAM REGISTRATION The student is applying for the following program: Secondary School: September to June (Full Year) September to January (First Semester) February to June (Second Semester) One-Month, One-Credit Program: Middle School: September to June (Full Year) September to January (Half Year) February to June (Half Year) Two-Week Summer Camp PROFICIENCY IN ENGLISH It is not necessary to write the TOEFL or TOEIC in order to be accepted into the Peel Academy. Have you written the TOEFL Test? Yes No TOEFL Score: Have you written the TOEIC Test? Yes No TOEIC Score: Have you written the IELTS Test? Yes No IELTS Score: EDUCATION GOALS AND DIRECTIONS Have you applied to the Peel Academy for International Students before? Yes No If yes, which program? Favourite Subjects: Difficult Subjects: Strengths:
4 Hobbies/Interests Post Secondary Plans and Future Career Direction (ex. University/College): EDUCATIONAL BACKGROUND Level/Type of School Country Dates Attended Grade/Form Last Attended Language(s) of Instruction Elementary (if applicable) Middle/Junior High School Senior High School Private School MEDICAL INFORMATION Are there any medical conditions we should be made aware of? Yes No If yes, please specify: Is the student on any medication? Yes No
5 If yes, please specify: Does the student have a disability that requires special education support? Yes No If yes, please specify: Does the student have any allergies? Yes No If yes, please specify: Please note that the Peel District School Board does not provide special education support for international students. SIBLINGS IN PEEL DISTRICT SCHOOL BOARD Last Name First Name School Attending Last Name First Name School Attending
6 REFERRAL AND AGENT INFORMATION How did you hear about the Peel Academy for International Students? Peel Academy website Friends or family Education fair Agency Please specify: Other Please specify: To be completed by the agent: Name of agency Contact person Address City Province/Sate Postal Code Phone Number PAYMENT OF FEES All fees must be paid in advance. Tuition fee and application fee must be received by the Peel District School Board before a letter of acceptance is issued. Fees may be paid by wire transfer. Please see for more details. Fees may be paid by wire transfer. Please see for more details. DOCUMENTS TO BE INCLUDED fully completed and signed application form non-refundable application fee ($500), paid to the Peel District School Board copy of personal educational documents (transcripts) in English 2 passport-sized photographs to be used for student ID cards REFUND POLICY If the request for a Study Permit is denied by Citizenship & Immigration Canada, a full refund, less the administration fee ($500.00), will be granted. To obtain a refund, the student must provide: 1. The original Letter of Rejection from Citizenship and Immigration Canada 2. The original letter of acceptance from the Peel District School Board 3. The original receipt of paid tuition fees If the student has not applied for a Study Permit and has withdrawn the application prior to the commencement of school, a full refund, less an administration fee ($750.00), will be granted. To obtain a refund the student must provide: 1. The original letter of acceptance from the Peel District School Board 2. The original receipt of paid tuition fees
7 There will be no refund of tuition fees if any one of the following applies: 1. after a Study Permit has been granted using the official letter of acceptance if the student chooses to withdraw for any reason. 2. after commencement of studies. 3. if the student is found in violation of school regulations and has been withdrawn from school as a result. 4. if the student changes immigration status during the year. Students who become permanent residents of Canada after school fees are paid will not be entitled for a refund. Health Insurance Refund Policy In the event you must cancel your policy and it was never used, the remaining health insurance fees will be returned following the waiting period required by Student Guard, minus a $50.00 CAD administration fee. We believe it is important for students to have medical coverage while in Canada. If a student withdraws from the Peel District School Board, students must contact Student Guard directly to receive a partial refund or continue coverage. Please allow 4-6 weeks for refund to be issued. PARTICIPATION AGREEMENT Students, regardless of age, must abide by the following conditions: 1. The student must obey the laws of Canada, the Province of Ontario and follow the rules, guidelines and policies of the Peel District School Board and the school in which the student is enrolled. 2. The student must follow all specific school and board regulations regarding attendance, course responsibilities and behaviour. 3. The student and family acknowledge that based on the information in the application, the Peel District School Board has the right to make educational decisions, including placement and program selections in the best interests of the student within the available resources. 4. The student and family understand and agree that inaccuracies in the application or failure to abide by the above conditions may result in immediate dismissal from the Peel District School Board without refund of tuition fee. 5. The student will continue to involve his or her parent/guardian while in this program, and will provide direction to the Peel District School Board to continue communication with the parent/guardian after the student turns 18 years of age. I have read, understand, and agree to follow the rules and guidelines as outlined above: Signature of Student Year/Month/Day Signature of Parent/Guardian Year/Month/Day GENERAL RELEASE/WAIVER 1. We, the undersigned, do waive and release all claims against the Peel Academy for International Students and the Peel District School Board for the injury, loss, damage, accident, delay or expense resulting from the applicant s participation in the Peel Academy. We also release the Peel District School Board and agree to indemnify it, with regard to any financial obligations or liabilities that the applicant may personally incur, or any damage or injury to the person or property of others that the applicant may cause while participating in the Peel Academy for International Students. 2. We understand that the Peel District School Board is not responsible for any loss or injury suffered by the applicant during periods of travel and study. If the applicant becomes ill or incapacitated, the Peel District School Board may take such action as it considers necessary, including securing medical treatment and transporting the applicant home at his/her own expense. We release the Peel District School Board from all liability related to such actions. We understand that the applicant s participation in the program may be terminated at the discretion of the Principal without any refund of tuition fee, and that the applicant may be sent home at his/her own expense if he/she does not adhere to the school or Peel District School Board rules, standards and instructions as set forth in the school s agenda and handbook. This agreement with the Peel District School Board cannot be modified or interpreted except in writing by the Peel District School Board.
8 3. The student and family acknowledge that based on the information in the application, the Peel District School Board has the right to make educational decisions, including placement and program selections in the best interests of the student within the available resources. 4. The student and the parent/guardian warrant that the student applicant has no history of criminal behaviour. Any disputes of a legal nature must be resolved through the courts of Ontario. 5. We understand that placement in a school is subject to availability of space. The Peel District School Board reserves the right to determine final school and grade placement. 6. We fully understand the refund policy of the Peel Academy. We understand that the Peel District School Board shall not be held liable for losses or expenses as a result of the Peel District School Board being unable to provide education owing to labour disputes, force majeure, or other causes beyond its control. I have read, understand, and agree to follow the rules and guidelines as outlined above: Signature of Student: Year/Month/Day Signature of Parent/Guardian: Year/Month/Day Please submit complete application form to: Peel District School Board Peel Academy for International Students 5650 Hurontario Street Mississauga, Ontario, Canada L5R 1C6 Tel: ex Fax: peelacademy@peelsb.com To complete your registration, you must remit payment by wire transfer. You will require this information in order to process the transfer: Swift #: CIBCCATT Bank Name: Canadian Imperial Bank of Commerce Bank Address: 1 City Centre Drive, Mississauga, Ontario L5B 1M2 Beneficiary Name: Peel District School Board Transit No: Bank No: 010 Account No: Please notify the Peel Academy of all bank transfers within 24 hours of transaction. A copy can be faxed to or ed to peelacademy@peelsb.com
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