RESIDENT BOARDER’S Picture

PERSONAL DATA 2x2

CHEMIN

________________________ Student/Reviewee/Professional

NAME ________________________________________________________________________
Surname First Name M.I

Home or Provincial Address _______________________________________________________

______________________________________________________________________________
Mobile phone _____________________ E-mail address_________________________________
Date of birth __________________________ Birthplace ________________________________
Citizenship ___________________________ Religion _______________________________
Age ___________ Sex: M F Civil Status: Single Married Divorced/Separated
Name of Spouse (if married) ______________________________________________________
Language(s) & Dialect(s) Spoken ___________________________________________________
School (HS/College) Graduated ______________________________Year __________________
Any pre-existing medical conditions (allergies, intolerance, on-going medication etc. :
______________________________________________________________________________
If professional, monthly income: ___________________________________________________
Father _________________________________ Occupation _____________________________
Mother (Maiden Name) ____________________ Occupation ____________________________
Telephone* (person to contact in case of emergency) _________________________________

City Guardian ____________________________ Relationship ___________________________

Address _______________________________________________________________________

• Boarding House or Dorm Residence Prior to SLRSCC (if applicable);

Name _____________________________________________________________________
Address_____________________________________________ Telephone______________
• School/Review Center presently enrolled (if applicable):
Name ______________________________________________________________________
Address ___________________________________________ Telephone _______________

V.2016.02
 RESTRICTION DATA

1. I allow my son/daughter (below 18 yrs old) to stay overnight:

With relatives □ Yes □ No
With friends □ Yes □ No
2. In normal or emergency cases, (s)he may go home to the province.
□ Alone □ With relatives □ Other (please specify) _______________________
3. In case of illness or sickness and there is a need for hospitalization, do you have a preferred
hospital? _________________________________

□ Ward □ Semi-Private Room □ Private Room

I (We) certify that above data and statements are true and correct to the best of my (our)
knowledge and ability.

Boarder’s Signature ___________________________________

Parent’s or Guardian’s Signature_________________________

Date___________________

V.2016.02