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ESW – Student File Form

This form serves as an aid to our Education Support Workers, in the good keeping, and accuracy of their records.

To review and update with Parents/Guardians when they apply for School Supply Funding

Date

DD slash MM slash YYYY

School Attending:

Student Personal Information

Name

First Middle Last

Student’s Dan Ke name or First Nation name :

First

Birth date:

DD slash MM slash YYYY

Age

Self-identified gender :

C.A.F.N. Enrolled Citizen?

Yes

No

C.A.F.N. Non Enrolled Citizen?

Yes

No

Clan/Moiety:

Crow

Wolf

Mother’s name:

First Last

Father’s name:

First Last

Legal Guardian:

First Last

Other siblings living in same home?

Yes

No

Number of siblings

Age sibling 1

Age sibling 2

Age sibling 3

Age sibling 4

Age sibling 5

Main Contact Info

Main contact name :

First Last

Cell Phone

Work Phone

Home Phone

Student main mailing / residence address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other mailing address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Main e-mail address:

Would you like to be added to our group mailing list to obtain the Education Department Newsletter, general information, student’s opportunities such as events or bursaries? (your e-mail address will remain confidential)

Yes

No

Student e-mail address:

Would you like to be added to our group mailing list to obtain the Education Department Newsletter, general information, student’s opportunities such as events or bursaries? (your e-mail address will remain confidential)

Yes

No

Other e-mail address:

Would you like to be added to our group mailing list to obtain the Education Department Newsletter, general information, student’s opportunities such as events or bursaries? (your e-mail address will remain confidential)

Yes

No

Health Information

Allergies:

Medical Conditions:

Is Student currently taking any Prescription Medications or Supplements?

Yes

No

Specify:

In Case of Emergency

Name of local friend or relative (not living at same address):

First Last

Relationship to student:

Home phone no.:

Work phone no.:

Name of another local friend or relative (not living at same address):

First Last

Relationship to student:

Home phone no.:

Work phone no.:

Are your child attend Secondary School?

Yes

No

Best way to contact your child

In school by call on the Public Announce system (PA)

Text message

E-mail

Please provide your child cell phone number

For all text message sent on your child cell phone, a copy will be sent to parents/guardian cell phone number as well

Please provide your child e-mail address

For all e-mail send by ESW to your child, parents/guardian will always be in C.C

Education Information

Is this student transferring to/from another school or Territory/Province?

Yes

No

Please provide School Name, Town/City, Prov./ Ter. :

Subject’s Student excels in:

Subject’s that require extra support:

External Support involved?

Yes

No

Please clarify about External Support

Name of organisation that provided extra support :

Behavioral Assessment

Yes

No

Does student have IEP (Individual Learning Plan) in progress?

Yes

No

Student supports being used at school?:

Yes

No

Please list the support

Cultural Interest:

Comments or areas of identified needs :

Parent / Legal Guardian signature:

Date

MM slash DD slash YYYY

TO BE FILLED OUT BY ESW

CAFN Consent form signed?

Yes

No

Validity:

1 Year

Until graduation

Date of end of validity

MM slash DD slash YYYY

Estimated date of end of validity

MM slash DD slash YYYY

School Supply Funding requested?

Yes

No

Special Circ. Funding requested?

Yes

No

Details

Board & Room Funding requested?

Yes

No

Tutoring Funding requested?

Yes

No

Kindergarten – Elementary

Grade

Year

Grade

Year

Grade

Year

Grade

Year

Grade

Year

Grade

Year

Grade

Year

Grade

Year

Grade

Year

Secondary

Grade

Year

Grade

Year

Grade

Year

Grade

Year

Grade

Year

Grade

Year

Grade

Year

ESW signature

Date

MM slash DD slash YYYY

Last Updated

Date

MM slash DD slash YYYY

Initials

Date

MM slash DD slash YYYY

Initials

Date

MM slash DD slash YYYY

Initials

Date

MM slash DD slash YYYY

Initials

Date

MM slash DD slash YYYY

Initials

Date

MM slash DD slash YYYY

Initials

Δ

HAINES JUNCTION OFFICE

#1 Allen Place, P.O. Box 5310
Haines Junction, YT Y0B 1L0
867-634-4200

WHITEHORSE OFFICE

304 Jarvis Street
Whitehorse, YT Y1A 2H2
867-456-6888

COMMUNITY BUILDINGS

Takhini Hall 867-667-6701
Da Ku Store 867-634-3307
Youth Center 867-634-2012
Mun Kų 867-634-7001
Champagne Hall 867-634-2336
Klukshu Hall 867-634-2342

[email protected]

Staff Directory

Forms

Popular topics:

Popular topics:

ESW – Student File Form

Student Personal Information

Main Contact Info

Health Information

In Case of Emergency

Education Information

TO BE FILLED OUT BY ESW

Kindergarten – Elementary

Secondary