Halton Catholic District School Board

Completed Pupil Attestation Form

Program Information

Does your student currently attend school in the Halton Catholic District School Board?
No
Has your student ever attended a Halton Catholic District school in the past?
No

What grade is the student applying for?

Secondary (Grades 9-12)

Please select 'Next' to continue.

Student Information
Legal First Name Sadia Gender Female
Legal Middle Name Date of Birth 3/28/2010
Legal Last Name Asim Enrolling Grade 9
Preferred First Name Sadia St. Francis Xavier Catholic Secondary
Enrolling School
School

Home/Residential Information

Main Phone Number 437-607-2154

Address 833 Whaley Way, Milton, Ontario
Apt / Unit 833
City Milton
Province Ontario
Postal Code L9T 0Z2

Mailing Address

Is the student's mailing address different than the physical address listed above?
No

Sacraments

Obtained Baptism? No
Obtained Reconciliation? No
Obtained Communion? No
Obtained Confirmation? No

New Student Information

Citizenship

Is your child a Canadian

No
Citizen?
You must select the
appropriate Citizenship for Refugee Status
your child:

Only full-time degree or diploma programs are valid. A language program on its own is not valid. Please contact planning.services@hcdsb.org
for more information.

Country of Citizenship Pakistan

Date of Entry to Canada 05/09/2024

Original Citizenship and Immigration documents must be produced if student is new to Canada.

Submitted 6/20/2024 Page 1 of 7

Halton Catholic District School Board Completed Pupil Attestation Form (Sadia Asim)

Birth Certificate or Citizenship Document(s)

Please upload student's

Birth Certificate or other
PHOTO-2024-06-20-10-56-56.jpeg
applicable citizenship
document(s)
Document Uploaded Passport
[ ] I am unable to upload the requested document(s) at this time. I understand that enrollment is NOT complete until the school has all
required documents. I will bring the missing document(s) to the student's school.
[X] You understand these documents will be used for verification purposes only. Once the verification process is complete, these
documents will be destroyed.

Place of Birth

Country of Birth Saudi Arabia

City of Birth Dammam

Voluntary First Nation, Metis, and Inuit Self-Identification

All parents/guardians of Indigenous students, and students who are 18 years or older, have the right to voluntarily and confidentially self-identify
their Indigenous ancestry.

If you wish to declare the student is Indigenous, please select one:

Home Language Survey

Which language did your son or daughter learn when he/she first began to talk?
Urdu
What language does your son or daughter most frequently use at home?
English

Previous School Information

Has this student ever attended school before?

No

Special Programs

Is the student in a Gifted Program?

No
Has the student been receiving English as a Second Language (ESL) assistance?
Yes
Does the student have special education needs and/or an Individual Education Plan (IEP)?
No

Family Information
Is there a separation agreement or court order in place related to custody or decision-making responsibilities?
No

Parent/Guardian 1

Title Mr.
First Name Muhammad
Middle Name
Last Name Asim
Suffix
Gender Male
Relationship to Student Father
Primary Contact Yes
Contact Citizenship Refugee Status

Please upload applicable citizenship document(s)

Submitted 6/20/2024 Page 2 of 7

Halton Catholic District School Board Completed Pupil Attestation Form (Sadia Asim)

PHOTO-2024-06-20-10-56-55.jpeg
Document Uploaded Passport
[ ] I am unable to upload the requested document(s) at this time. I understand that enrollment is NOT complete until the school has all
required documents. I will bring the missing document(s) to the student's school.
[X] You understand these documents will be used for verification purposes only. Once the verification process is complete, these
documents will be destroyed.
Emergency Contact Yes
Has custody Yes
Can pick up student Yes
Lives with student Yes
Access to School Records? Yes
Speaks School Language? Yes
Resides at 833 Whaley
Yes
Way, Milton, Ontario
Receives mail for student Yes

Parent/Guardian 1 Contact Information

Phone 1 Number 437-607-2154

Phone 1 Type Mobile
Preferred phone number? Yes
Accepts SMS? Yes
Phone 2 Number
Phone 2 Type
Preferred phone number?
Phone 3 Number
Phone 3 Type
Preferred phone number?

Personal Email Address loprin100@gmail.com

Parent/Guardian 2

Title Mrs.
First Name Kiran
Middle Name Fatima
Last Name Asim
Suffix
Gender Female
Relationship to Student Mother
Primary Contact Yes
Contact Citizenship Refugee Status

Please upload applicable citizenship document(s)

PHOTO-2024-06-20-10-56-56.jpeg
Document Uploaded Passport
[ ] I am unable to upload the requested document(s) at this time. I understand that enrollment is NOT complete until the school has all
required documents. I will bring the missing document(s) to the student's school.
[X] You understand these documents will be used for verification purposes only. Once the verification process is complete, these
documents will be destroyed.
Emergency Contact Yes
Has custody Yes
Can pick up student Yes
Lives with student Yes
Access to School Records? Yes
Speaks School Language? Yes
Resides at 833 Whaley
Yes
Way, Milton, Ontario
Receives mail for student Yes

Submitted 6/20/2024 Page 3 of 7

Halton Catholic District School Board Completed Pupil Attestation Form (Sadia Asim)

Parent/Guardian 2 Contact Information

Phone 1 Number 437-601-2154

Phone 1 Type Mobile
Preferred phone number? Yes
Accepts SMS? Yes
Phone 2 Number
Phone 2 Type
Preferred phone number?
Phone 3 Number
Phone 3 Type
Preferred phone number?

Personal Email Address asimkiranasim@gmail.com

Additional Parent/Guardian

Would you like to add

No
another parent/guardian?

Emergency Contact Information

Please list emergency contacts other than: Muhammad Asim, Kiran Asim, ,

Emergency Contact 1

Title Mr.
First Name Sajid
Middle Name Latif
Last Name Yasin
Suffix
Relationship to Student Family Friend
Can pick up student Yes
Lives with student No

Emergency Contact 1 Contact Information

Phone 1 Number 587-936-2513

Phone 1 Type Mobile
Preferred phone number? Yes
Accepts SMS? No
Phone 2 Number
Phone 2 Type
Preferred phone number? No
Phone 3 Number
Phone 3 Type
Preferred phone number?

Personal Email Address loprin100@gmail.com

Additional Emergency Contact

Would you like to add

another emergency No
contact?

Emergency Contact Priority

To adjust the priority in which emergency contacts will be called, please select the appropriate order number next to the name.

Muhammad Asim 1
Kiran Asim 2
Sajid Yasin 3
Submitted 6/20/2024 Page 4 of 7
Halton Catholic District School Board Completed Pupil Attestation Form (Sadia Asim)

Student's Medical Information

Health History
It is important that the school be aware of any special health problems your child has.
Please answer the questions below and provide any information necessary for the care, and safety, of your child.

Does your child have a (any) diagnosed prevalent medical condition(s) (e.g., anaphylaxis, asthma, diabetes, epilepsy and seizure
disorder, heart conditions/SADS, sickle cell anemia, other)?
No

Does your child have any other health issues that we should be aware of?
No

Immunization Record
Please visit Halton Health region for information about immunization records.

Transportation
To determine whether a student is eligible for student transportation, please visit the HSTS Transportation Eligibility Search tool. Note that student
transportation eligibility will be confirmed by the Halton Student Transportation Services (HSTS) based on the Board’s transportation policies and
procedures.

Agreements
Acceptable Use Policy

Please read the Acceptable Use Policy I-43 Use of Technology and Digital Citizenship.

[X] I have read and agree to the terms of the policy.

Permission to Photograph/Video

The Halton Catholic District School Board (the Board) likes to share good news stories. From time to time, school and/or classroom activities such
as student projects, achievements, activities, plays, athletics and presentations are photographed or recorded by school or Board staff. Sharing
these photographs and recordings is a wonderful way to celebrate and remember these activities and to highlight our good news stories.

Please note:
Š These recordings/photographs may be used in school and Board newsletters, and/or school/Board websites and social media. Individual
students will only be photographed and identified with appropriate consents.
Š When the media, such as newspapers, television and radio, are invited to the school for the purposes of reporting on ne wsw orthy events
or activities, their reports may include non-identifying photos of groups of students.
Š Parents, guardians, students age 18 and over must be aware that when students participate in extra-curricular or non-compulsory activities
off school grounds, the school principal is unable to control or prevent any media exposure, which may occur.

I give permission.
Yes
I consent to the sharing of my child's name and photo in the annual school yearbook and/or class photos.
Yes

School Emergency Closure

In the event of an emergency requiring us to dismiss school early due to snow, broken water pipes, fire, etc., we must have a plan for getting every
student home safely.

Look over the plans below and choose the one that would be best for your child.

Please discuss the plan with your child and review it with him/her often.

My child is: Walker

Please select: Option A: YES, the school may dismiss my child with NO telephone call required.
Electronic Signature Muhammad Asim
Today's Date 06/20/2024
NOTE: If your plans change during the school year, please inform us in writing. We will use the information listed above unless you notify us
differently.

CONSENT TO DISCLOSE CHILD/CHILDREN'S NAME

Submitted 6/20/2024 Page 5 of 7
Halton Catholic District School Board Completed Pupil Attestation Form (Sadia Asim)

During the school year, students may be involved in a wide variety of events and activities consistent with the purpose of educating students in
accordance with The Education Act. It is an established practice for our school/Board to display and communicate information about these
activities within the school or community. When displaying this information, we may include your child/children 's name as outlined below.

I consent to:
Š The disclosure of my child/children 's written/creative work, and name through such activities as science fairs, art projects, poster contests,
bulletin board displays, yearbooks, school newsletters, school websites and/or Board website or the Board's social media channels;
Š Posting lists of student names inside the school to inform students and parents of school clubs or school teams.

I Agree: Yes

SCHOOL COUNCIL

I authorize permission for the release of information (telephone number and email only) to Catholic School Council members so that they may
contact me.

I Agree: Yes

LOCAL CATHOLIC PARISH

I authorize permission for the release of limited information to our local parish so that they may send me parish information and updates.

I Agree: Yes

CONSENT FOR PARTICIPATION IN ACTIVITIES

Throughout the school year, there will be occasions when your child / children will be asked to participate in field trips within walking distance of the
school. This may involve a walk to the Church, local park, plaza, etc. Teachers may also engage student in Daily Physical Activity (DPA) that takes
place off school grounds and follow the HCDSB Physical Education Safety Guidelines. For these activities, teachers must have permission from
the principal/designate with time of departure and return, with the route of the "trip" destination outlined and a list of student participants.

The participation of students in these activities in the community have an inherent risk that may result in loss, injury or death. Some of the risks
include, but are not limited to weather conditions, walking, and running.

I hereby consent to the participation of my child / children in activities related to the curriculum during regular school hours beyond school grounds
in the neighbourhood, provided such activities are supervised by members of your school staff, as per Board supervision day trip ratios. I confirm
that I have reviewed the information provided by the Halton Catholic District School Board regarding excursions into the community. I acknowledge
that I understand that accidents resulting from excursions into the community may occur and may result in injury and/ or loss. I acknowledge that
excursions into the community contain an element of risk, which I have discussed with my child / children. I understand and acknowledge that the
Board does not provide medical or accident insurance for students, and my child should be a member of a medical insurance plan and that in
case of accident, injury or loss.

I Agree: Yes

CODE OF CONDUCT

I have read the Code of Conduct located on the school and/ or Board websites, as well as student agendas, where applicable. I have reviewed and
discussed the contents therein with my child/children.

I Agree: Yes

Document Upload
Below for your convenience, you may optionally upload documents for registration.

If you do not have access to digital copies of these documents, a scanner or a camera, you must bring all applicable documents for registration to
the student's school.

Proof of Residency

Please upload a proof of

Basement-Signed Agreement between Dr. Asim and Inam.pdf
address
Document Uploaded Agreement of Purchase and Sale
Additional proof of address
NO DOCUMENT UPLOADED
upload (optional)
Document Uploaded
[ ] I am unable to upload the requested document(s) at this time. I understand that enrollment is NOT complete until the school has all
required documents. I will bring the missing document(s) to the student's school.
[X] You understand these documents will be used for verification purposes only. Once the verification process is complete, these
documents will be destroyed.

Electronic Signature
Submitted 6/20/2024 Page 6 of 7
Halton Catholic District School Board Completed Pupil Attestation Form (Sadia Asim)

The electronic signature and all of its related fields replaces a handwritten signature on paper and is legally binding.

I affirm that the information provided is true, correct and complete, to the best of my knowledge and belief. This electronic signature and its related
fields are treated like a handwritten signature on a paper form.

Parent/Guardian Signature

I Agree Yes Today's Date 06/20/2024

Electronic Signature Muhammad Asim

For Office Only

Entry Code
Entry Date
Board Status
Principal Signature:

Submitted 6/20/2024 Page 7 of 7