Boarding Home Program Application

Boarding Home Program Application

This form is ONLY for Parent(s) or Guardians of Students Applying for the Program
The purpose of the Athabasca Tribal Council Boarding Home Program is to provide placement services to students attending high school in the Alberta region. The boarding home family provides room and board to a high school student. The objective is to have the student integrate with the family while being provided with residential accommodation and academic/personal support in a safe and supportive environment while the student pursues his/her high school education.

Please read the Boarding Home Program Handbook before filling out this form.

If you have any questions or concerns, please contact:

CHARLES NOKOHOO
Education Coordinator

780-791-6538 *243

charles.nokohoo@atcfn.ca
Boarding Home Program Handbook

Required Information
Student's Information
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Current address at time of application*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Residence*
First Nation*
Treaty #*
Alberta Health Care #*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Grade Level*
Last Three Schools Attended
1 - Name of School *
Location of School*
Grade Completed*
2 - Name of School *
Location of School*
Grade Completed*
3 - Name of School *
Location of School*
Grade Completed*
Health History
If the student has any allergies, please list them down below:*
Is the student currently taking any medications? If yes, please list them down below:*
Was the student previously hospitalized or undergone any surgery?*
Please indicate any health and medical conditions your child may have.*
Please indicate any learning disabilities your child may have.*
Requested Information
Please indicate you child's Family Physician information
Doctor's Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Last Check Up

MonthDayYear
Date
If your child has not seen a family doctor in the last 12 months, it is highly recommended for your child to get a check-up along with a check up of their bloodwork and ensure they are in good health for the upcoming school year.
Please indicate you child's Dental information
Dentist's Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Last Check Up

MonthDayYear
Date
Please indicate you child's Optometrist information
Name of Eye Doctor
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Last Check Up

MonthDayYear
Date
Does your child have a prescription from an eye doctor indicating they need glasses?
If you child requires eyeglasses, do they have a pair of glasses that has a current prescription?
Please Provide a copy of the following: Birth Certificate

Cancelof
Please Provide a copy of the following: Alberta Health Care Card

Cancelof
Please Provide a copy of the following: Alberta Identification Card

Cancelof
Please Provide a copy of the following: Certificate of Status Indian Card

Cancelof
Please Provide a copy of the following: Social Insurance Number.

Cancelof
Social Insurance Number
Only supply if no copy was uploaded.
Student's Direct Deposit Information

Student's monthly allowance will be deposited directly.
Direct Deposit Banking Information Form, or Copy of Void Cheque

Cancelof

Required Information
Parent/Guardian's Information
Parent/Guardian's Name - Primary*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Residence*
Email*
example@example.com
Phone Number - Home*
Please enter a valid phone number.
Phone Number - Work
Please enter a valid phone number.
Phone Number - Cell
Please enter a valid phone number.
Relationship to Student*
Parent/Guardian's Name - Secondary

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Residence
Phone Number - Home
Please enter a valid phone number.
Phone Number - Work
Please enter a valid phone number.
Phone Number - Cell
Please enter a valid phone number.
Relationship to Student
In case of emergency, who will be notified? Please answer the fields below:
First Emergency Contact Person*

First NameLast Name
Emergency Phone Number*
Please enter a valid phone number.
Relationship to Student*
Second Emergency Contact Person*

First NameLast Name
Emergency Phone Number*
Please enter a valid phone number.
Relationship to Student*

I hereby make application for my child to attend school in:
Name of School*
If Selected Other, Name of School:
School Location:
Grade:*
Expected Start Date*

MonthDayYear
Date
Expected End Date*

MonthDayYear
Date
Reason for Application:*

AUTHORIZATION TO RELEASE ENROLLMENT/ACADEMIC INFORMATION
I consent to release all attendance, enrollment and academic information to the Athabasca Tribal Council for the duration of this
20 year* /20 year* academic year.
Name of Parent/Guardian*

First NameLast Name
Signature of Parent/Guardian*

Clear
Name of Student*

First NameLast Name
Signature of Student*

Clear
Date*

MonthDayYear
Date

PHOTO RELEASE FORM
I Student Name* hereby consent to photographs or film being taken of my likeness and grant to the Athabasca Tribal Council and its legal representatives and assigns the irrevocable and unrestricted right to use and publish photographs of myself or in which I may be included, for editorial, trade, advertising and any other purpose, and in any manner and medium; to alter the same without restriction; and to copyright the same. I hereby release the Athabasca Tribal Council and its legal representatives and assigns from all claims and liability relating to said photographs.
Student Name*

First NameLast Name
Student Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

STATEMENT OF PARENTS/GUARDIANS

I authorize the Athabasca Tribal Council and/or the boarding home parent(s) to carryout the following on my behalf:

1. To grant permission for medical, surgical, or dental treatment of which my child/ward may require. This may include examination or tests, immunization, inoculation, anesthetic, admission to and treatment in the hospital. I understand that the need of any of the above will be determined by a competent medical authority.

2. To apply for admission of my child/ward to secondary/vocational school or special training if necessary and for the Athabasca Tribal Council officials to arrange the school.

3. To obtain necessary school information such as report cards and attendance.

In addition, I will assume the following responsibilities:
1. To make the necessary arrangements for home placement of my child/ward.

2. Although my child is in the care of the boarding home parent, I will continue to fulfill the parental/guardianship duties and responsibilities of my child as outlined in the Athabasca Tribal Council Boarding Home Handbook.

3. I agree to ensure my child/ward has adequate and proper clothing, which will be required for school programs, and to meet the varying climate conditions while my child/ward is in the boarding home.

4. I agree to provide my child/ward with any additional monies required for personal spending.

5. I understand that boarding home parents are not responsible for the payment of long distance or for collect calls. It is my responsibility to provide a calling card for my child/ward.

6. I understand that the child/ward will be expected to abide by boarding home rules previously established by myself, the home, and the Athabasca Tribal Council. Should my child not live up to these expectations, he/she may be withdrawn from the Boarding Home Program.

7. I assume responsibility for encouraging my child/ward to attend school regularly, to obtain school information, and to attend parent and teacher interviews.

8. I understand that regular home visitations at my child/ward’s residence are welcomed, provided I make prior necessary arrangements.
Date Signed*

MonthDayYear
Date
Parent/Guardian Signature*

Clear

BOARDING HOME STUDENT CONTRACT

This contract is to be read, understood and signed by the boarding home student themselves.
Full Name of Student* agree to the following conditions while attending school and living as a guest in a boarding home:
1. To respect and adhere to the rules of the boarding home parent(s), school authorities, and the ATC Education Coordinator.
2. To attend school every day and to notify my boarding home parent should I have a legitimate reason for being absent.
3. To devote effort and study time to the courses I am enrolled in and to complete all assigned school work to the best of my abilities.
4. To inform my boarding home parents and the Education Coordinator of any circumstances which are interfering with my performance at school.
5. I agree to accept my responsibilities as outlined in the Boarding Home Program Handbook.
Date Signed*

MonthDayYear
Student Signature*

Clear
Please verify that you are human*
Should be Empty:

Required Information

Student's Information

Last Three Schools Attended

Health History

Requested Information

Please indicate you child's Family Physician information

Please indicate you child's Dental information

Please indicate you child's Optometrist information

Student's Direct Deposit Information

Required Information

Parent/Guardian's Information

I hereby make application for my child to attend school in:

AUTHORIZATION TO RELEASE ENROLLMENT/ACADEMIC INFORMATION

PHOTO RELEASE FORM

STATEMENT OF PARENTS/GUARDIANS

BOARDING HOME STUDENT CONTRACT