Welcome to Khalsa School!
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Welcome to Khalsa School!
Waheguru Ji Ka Khalsa, Waheguru Ji Ki Fateh!
Khalsa School is a unique Sikh Private Educational Institution with a closed campus policy. We have a drug,
alcohol and smoke free environment. Khalsa School is a place where students’ lives are enlightened
with the highest moral and spiritual values. Khalsa School has established very high standards for our
academic and religious education programs. Students take part in a variety of sports
tournaments, academically and religiously oriented competitions and scores of
other extra-curricular activities. Children also learn the Sikh Way of Life.
We are delighted to educate your child.
Visit our website for more information or contact us.
Thank you!
Administration
Khalsa School Surrey
Khalsa School Newton campus Ph.:604-591-2248
Khalsa Primary School Ph.:604-597-6464
Khalsa Old Yale Road Campus Ph.: 604-951-2333
Khalsa Secondary School Ph.: 604-585-8200
E-mail: info@khalsaschool.ca
Website: www.khalsaschool.ca
12015-2016 Khalsa School Session fees
1. Tuition fee is to be paid as follows:
a. Full year payment: Paying for full year claim 5% discount (if paid by cash or cheque) or 2% discount (if paid
by Visa /Master card or debit) at the time of Registration.
b. Payment in 3 installments: If paying for 4 months (September to December) or 5 months for KG of KPS
(August to December) and 2 instalments of 3 months each (January to March and April to June) by post-
dated cheques or Pre Authorization of credit card, there is no discount and parents will be required to sign
an authorization form and a consent form. No payment on monthly basis will be accepted.
If you want to pay 2nd and 3rd instalments by cash, give us post-dated cheques or pre authorization of credit
card with dates and if we receive cash before that date, we will not process the cheque or credit card.
c. Monthly Tuition fees:
1. KG of KPS only: $110
2. Grade 1 to 7 (KSN) : $150
3. K.G to Grade 7 (OYR) : $150
4. Grade 8 to 12 ( KSS): $160
d. NSF: For NSF cheques or two time credit card payment decline, $20 fees will be charged.
2. Parents pay the following fees also at the time of registration to Khalsa School:
a. Registration fees $125.00 (Non Refundable)
b. Agenda fee $10.00 (Non Refundable)
c. Year Book $10.00 (Non Refundable) -: Charged for one per family
d. Text book borrowing fee $50.00 (for Gr.1 to Gr. 12 only – Non Refundable)
e. Applied Science $25.00 (for Grades 8 to 12 only – Non Refundable)
3. The Parents have to pay for the whole year regardless of whether they take the child out during the school year.
Note: All Fees (Registration fee, Annual Fees, Tuition Fees, Bus Fee, &
Donations) are Non-Refundable/Non-Transferable.
2YEAR 2015-2016 STUDENT FEES
ANNUAL CHARGES
Agenda: $10.00 (K-10)
Year Book: $10.00 (K-10)
Text Book Borrowing: $50.00 (1-10)
Applied Sciences: $25.00 (8–10)
Registration Fee: $125 per child
Tuition Fee: GRADE 8 TO 12(Khalsa Sec. School OYR)
$160.00 Per month 1st child*10 months Sept/15 to June/16 - $1600.00 after discount $1520.00(cash & cheque only)
$160.00 Per month 1st child* 10 months Sept/15 to June/16 - $1600.00 after discount $1568.00(visa & mc only)
$140.00 Per month 2nd child* 10 months Sept/15 to June/16 - $1400.00 after discount $1330.00(cash & cheque only)
$140.00 Per month 2nd child* 10 months Sept/15to June/16 - $1400.00 after discount $1372.00(visa & mc only)
$125.00 Per month 3rd child* 10 months Sept/15 to June/16 - $1250.00 after discount $1187.50(cash & cheque only)
$125.00 Per month 3rd child* 10 months Sept/15 to June/16 - $1250.00 after discount $1225.00(visa & mc only)
GRADE 1 TO 7(Khalsa School Newton)
GRADE K TO 7(Khalsa School OYR)
$150.00 Per month 1st child*10 months Sept/15 to June/16 - $1500.00 after discount $1425.00(cash & cheque only)
$150.00 Per month 1st child* 10 months Sept/15 to June/16 - $1500.00 after discount $1470.00(visa & mc only)
$130.00 Per month 2nd child* 10 months Sept/15 to June/16 - $1300.00 after discount $1235.00(cash & cheque only)
$130.00 Per month 2nd child* 10 months Sept/15 to June/16 - $1300.00 after discount $1274.00(visa & mc only)
$115.00 Per month 3rd child* 10 months Sept/15 to June/16 - $1150.00 after discount $1092.50(cash & cheque only)
$115.00 Per month 3rd child* 10 months Sept/15 to June/16 - $1150.00 after discount $1127.00(visa & mc only)
* Students must be siblings – proof may be requested
KINDERGARTEN FEES (For Khalsa School Newton Only)
110.00 per month 1st child 11 months Aug/15 – June/16 - $1210.00 after discount $1149.50 (cash & cheque only)
110.00 per month 1st child 11 months Aug/15 – June/16 - $1210.00 after discount $1185.80(visa & mc only)
If 2nd child is in KG $105.00 11 months Aug/15 – June/16 - $1155.00 after discount $1097.25 (cash & cheque only)
If 2nd child is in KG $105.00 11 months Aug/15 – June/16 - $1155.00 after discount $1131.90(visa & mc only)
If 3rd child is in KG $100.00 11 months Aug/15 – June/16 - $1100.00 after discount $1045.00(cash & cheque only)
If 3rd child is in KG $100.00 11 months Aug/15 – June/16 - $1100.00 after discount $1078.00(visa & mc only)
Bus Fee:
Bus fee two way local (Surrey, Delta): $100.00 Bus fee one way local: $60.00
Bus fee long distance two way: $125.00 Bus fee long distance one way: $75.00
Please Note: All fees are not refundable
3KHALSA SCHOOL UNIFORM 2015-16
This is a list of uniform items. All items, except socks and shoes, can be purchased from the school. Parents must make sure that the
student has enough uniform sets to be in school uniform whenever he/she is attending this school. Starting this year 2015–16 the new
uniform will be in full effect. Students will not allowed to wear the old uniform.
KINDERGARTEN TO GRADE 7
REGULAR UNIFORM: BOYS
1. White kurta with white pajama. OR
2. Navy Blue polo shirt with the school logo and Grey Pants with the school logo.
3. Dark blue head covering – turban or rumal only (Grade 7 boys must wear turbans)
4. White socks and black comfortable dress shoes
REGULAR UNIFORM: GIRLS
1. White kameez with blue salwar OR
2. Navy Blue polo shirt with a logo and Grey Pants with a logo.
3. Dark blue head covering – turban or rumal only
4. White socks and black comfortable dress shoes
PHYSICAL EDUCATION (PE) UNIFORM KG TO GRADE 7
BOYS AND GIRLS
1. Dark blue jogging pants with the school logo including dark blue T-shirt with the school logo
2. Dark blue head covering (rumal or turban – Grade 7 boys must wear turbans)
3. White socks and runners without black soles
GRADE 8 TO 12
REGULAR UNIFORMS: BOYS
1. White Kurta with white pajama. OR
2 White polo shirt with the school logo and black pants with the school logo.
3. Dark black head covering – turban only
4. White socks and black comfortable dress shoes
REGULAR UNIFORM: GIRLS
1. White kameez with black salwar OR
2. White polo shirt with the school logo and black pants with the school logo.
3. Dark black head covering – rumal or turban
4. White socks and black comfortable dress shoes
PHYSICAL EDUCATION (PE) UNIFORM
BOYS AND GIRLS GRADE 8 TO 12
1. Dark black jogging pants with the school logo including dark black T-shirt with Khalsa School logo.
2. Dark black head covering rumal or turban for boys.
3. Runners without black soles & white socks only.
NOTE:
Not allowed:-- Tearaways, shorts, jeans, flairs, vests, earrings, rings, necklaces, nail polish, make up, baseball caps etc.
PE strips are for PE classes and lunch time only. However, Grade KG to 3 students are allowed to wear PE strips for full
day if they have PE classes on that day. All students are allowed to wear their PE strips for field trips if they wish to.
Students are reminded that dress shirts must be neatly and completely tucked in their waist band. No jackets are to
be worn in class or in the Gurdwara. Students without proper school uniform will be asked to go home or have their
uniform delivered to the school. If a student continually forgets their uniform then disciplinary action may be taken.
The students are responsible for their own clothes and belongings.
4Khalsa School
List of necessary School Supplies for all grades
Session 2015-16
# Supplies KG 1 2 3 4 5 6 7 8 to 12
1 Scissors 4.5” 1 1 1 1
2 Scissors 6” 1 1 1 1 1
3 Wax Crayons (Pack of 24) 1 1 1 1 1 1 1 1
4 Pencils with eraser (pack of Ten) 2 2 2 2 2 2 1 1 1
5 Pencil crayons – set of 24 1 1 1 1 1 1 1 1 1
6 Ruler 30cm. 1 1 1 1 1 1 1 1
7 Eraser – White Vinyl 2 2 2 2 2 2 2 2
8 Glue Sticks 6 6 6 6 4 4 4 4 4
9 Pencil Box or Pencil Case 1 1 1 2 1 1 1 1 1
10 Paper Clips 1 1 1 1 1 1 1 1
11 Felt Colors (24 Pack) 1 1 1 1 1 1 1 1 1
12 Fine Felt Pens (24 Pack) 1 1 1 1 1 1 1 1
13 Highlighters 1 1 1 1 1
14 Pens ( Blue & Red) Gel 6 6 6 6 6
15 Duo Tangs with pocket folders 10 10 10 10 10 10 0 10
16 Report Covers 5 5 5 5 5
17 Coiled Note Books (lined) 3 6 2 10
18 Note Books – Interlined 72 Page 4 4 4 6 6
19 Note Book – Half Interlined 72 Page 1 1 1 2 1
20 Note Book - Full lines 72 Pages 1 1 1 2 2 6 6 6 6
21 Pocket Folders 4 4 4 2 4 4 4 1 4
22 Graph paper pad (Pack of 100 Sheets) 1 1 1 1 1
23 Loose Leaf papers ( Packs of 200 Sheets) 2 2 4 4 6 6
24 Binders 3 ring 1.5” 1 1 1 1 1 6 3
25 Pencil Sharpeners 1 1 1 1 1 1 1 1 1
26 Tracing Paper Book 1 1 1 2
27 Scrap Paper Book 14” x 11” 1 1 1 1 1 1 1
28 Scotch Tape 1 1 1 1 1 1
29 Dictionary 1 1 1 1 1 1
30 Thesaurus 1 1
31 Scientific Calculator 1 1 1 1
32 Back Pack 1 1 1 1 1 1 1 1 1
33 Index Dividers 1 1 1 1
34 Geometry Set 1 1 1 1
35 Cloth bag with drawstring for PE strip 1 1 1 1 1
36 Agenda (from School) 1 1 1 1 1 1 1 1 1
37 Small Notebook for Kirtan class 1 1 1 1 1 1 1
38 French/English Dictionary 1 1 1
Note: 1. Students are not allowed to use liquid paper for corrections. Do not buy liquid paper.
2. Text Books will be issued by the school. Students will be required to pay for lost or damaged books. Report cards will not
be issued until student has paid any fines owing or school fees.
3. Write your child’s name on the school supplies.
5KHALSA SCHOOL SURREY
6NEWTON, OLD YALE ROAD, KHALSA HIGH SCHOOL
E-mail: kssinfo@khalsaschool.ca
Website: www.khalsaschool.ca
PLEASE ADMIT MY CHILD ________________________________TO GRADE ________________________________________
Child’s Family Name _____________________________________________ Male - Female (Circle 0ne)
Address______________________________________________________City____________________________________________
Postal Code _______________________ Home Phone No. ______________________________________
Date of Birth (Month) (Day) (Year) Place of Birth ___________________________Citizenship ______________
Child’s Religion ____________________ Amritdhari __Yes / No___Nitnem Daily Yes / No _____________________________
Previous School (Name) _________________________ & City/Prov./Country ____________________________________________
Grade Completed ____________ (Date) ____________
Level of Punjabi: Reading __________________________________ Writing _____________________________________________
Other children in this School: Name: ________________________________________Grade: ___________________________
Name: ________________________________________Grade: ___________________________
FATHER:
Name __________________________________ Occupation ______________________Religion _____________________
Phone (work) _________________________________Cell:_____________________________Email_________________________
MOTHER:
Name __________________________________ Occupation ______________________Religion _____________________
Phone (work) ________________________________ Cell:_____________________________Email_________________________
Or Legal Guardian:
Name __________________________________ Occupation ______________________Religion _____________________
Phone (work) _______________________________________ Cell:_____________________________________________________
Emergency contact if parents unavailable: Name __________________________________________________________________
Relation _______________________________ Phone: _______________________________________________________________
Bus Service required? ___________
I AGREE TO ABIDE BY THE SCHOOL PHILOSOPHY AND CODE OF CONDUCT (copy is attached) I understand that
all fees are non-refundable___________________________________ DATE: _________________
Parent/Legal Guardian Signature.
FOR OFFICE USE ONLY:
1. Birth Certificate: _____
2. Care Card:_____
3. Proof of Parent’s Status: _____
4. Proof of child’s Status: _____
5. Proof of Residence
6. Immunization record for KG students only
Verified By: __________________________
Admission Approval: ____________________________ ________________________
(Principal’s Signature) Date
7Khalsa School, Satnam Education Society
Student Medical Information
Please note that the following information is confidential
Student’s name __________________ Date of Birth: ______/____/____ Female or Male
Permanent Address: __________________ YYYY MM DD
__________________ Country of Birth: ____________
__________________ Citizenship: _____________
Home Phone Number ____________________ Parents Cell Phone Numbers______________
Students email address: _________________________ Parents email address: ______________________
Care Card No. _____________________
Physician’s Name _____________________
Address: _____________________
_____________________
Telephone _____________________
Emergency Contact Numbers:
Name Name
Phone # home: _____________________ Phone # home: _____________________
Work:___________________ Work:___________________
Cell:____________________ Cell:____________________
Relationship to student Relationship to student
Address Address
Medical History
Has the student ever experienced any of the following:
[ ] Arthritis [ ] Sleepwalking [ ] Heart Condition [ ] Diabetes [ ] Seizure Disorder
[ ] Ear Troubles [ ] Sinus Troubles [ ] Migraines [ ] Cancer [ ] Frequent Colds
[ ] Motion Sickness [ ] Epilepsy [ ] Hysteria [ ] Nose Bleeds [ ] Bronchitis
[ ] Tonsillitis [ ] Nightmares [ ] Rheumatism [ ] Fainting [ ] Asthma
[ ] Kidney Trouble [ ] Convulsions [ ] Skin diseases [ ] High Blood Pressure [ ] Anemia
[ ] Seasonal Allergies [ ] Nut Allergies [ ] Back or Neck pain [ ] Major Surgeries please specify
[ ] Other? Please give specifics.
8Medical History Continued……
Do you have any allergies?
[ ] Foods List foods:
Type of Reaction:
[ ] Insects Type of Insect:
Type of Reaction:
[ ] Drugs Name:
[ ] Hay fever List of Causes:
Type of Reaction:
[ ] Other Please give specifics
Please explain any specific treatment or drugs for any of the above listed allergies or ailments?
For example, Use of hypo-spray for asthmatic condition or anaphylactic injection for bee stings…..
Check one:
Excellent Good Poor Aids if Aids are used which ones:
Eyesight [ ] [ ] [ ] [ ] Glasses
Hearing [ ] [ ] [ ] [ ] Hearing Aids
[ ] Contact Lenses
Other Medical History
When was the last time the student had a Tetanus inoculation or booster (d/m/y)? ______________
Is the student taking any prescription or non – prescription drugs? [ ] yes [ ] no
Please Specify.
Name of Drug: _________________________________________________________________
Reason for taking drug: __________________________________________________________
All the information is accurate as of today’s date. If there are any changes, I agree to contact Khalsa School with
the updated information.
Date: ____________________ Signature of Parent or Guardian: _____________________
Printed Name: ______________________
9Khalsa School, Satnam Education Society
Consent to Medical Treatment
Student’s name __________________ Date of Birth: ____/____/____ Male or Female
Permanent Address: __________________ YYY MM DD
__________________ Country of Birth: ____________
__________________ Citizenship: _____________
Home Phone Number ____________________ Parents Cell #’s
Emergency Contact Name: _____________________ ______________________
Emergency Contact Number: _____________________ ______________________
I agree that Khalsa School accepts no liability in connection with the supervision or administrating of
medication to my child. Khalsa School will not supervise the administration of prescribed medication to
students unless the parent or guardian expressly authorizes the administration of medication at school, the
parent or guardian provides explicit written instructions regarding the manner in which the medication is to be
administered, and there is staff available to undertake this task.
1. I do hereby consent to administrating prescription medication and to emergency medical treatment to
my son/daughter while he/she is at Khalsa School.
Student Drug Allergies: ____________________________________
Signature Parent/Guardian: __________________________________
Printed Name: ___________________________________
Date: ____________________________________
2. I do not wish my son/daughter to be given any medication while he/she is at Khalsa School.
Signature Parent/Guardian: ___________________________________
Printed Name: ___________________________________
Date: ____________________________________
PHYSICIAN’S STATEMENT
I, ___________________________________________, am a qualified Physician licensed to practice in British
Columbia. I am the attending physician for _____________________________ and hereby approve and
authorize the medication and the administration of such medication referred to above.
DATED at _______________________________, B.C., _________________________ 201__.
____________________________
Physician Signature
Physician Printed Name &
Identification number
___________________
___________________
10KHALSA SCHOOL SURREY
NEWTON/OLDYALEROAD
Email: kssinfo@khalsaschool.ca
Website: www.khalsaschool.ca
CODE OF CONDUCT
AS A STUDENT OF KHALSA SCHOOL YOU ARE EXPECTED TO PRACTICE GOOD MANNERS AND
TREAT OTHERS WITH RESPECT AND KINDNESS; TO ACT ACCORDING TO THE PRINCIPLE OF
VIRTUE, EXCELLENCE AND GRACE; TO USE GOOD COMMON SENSE.YOU WILL EXCEL AS AN
INDIVIDUAL AND AS A SIKH.
SHOULD THESE EXPECTATIONS NOT BE MET BY A STUDENT, THERE WILL BE A WARNING,
DETENTION OR PARENT MEETING. IF NECESSARY, A STUDENT WILL BE SUSPENDED FROM
THE SCHOOL, WE HOPE THAT NO STUDENT WILL BE EXPELLED, BUT THIS IS AN OPTION IF,
DESPITE ALL EFFORTS, THE STUDENT’S BEHAVIOUR IS NOT CHANGED.
1. Unless a student has made arrangements with a teacher, the student should arrive no earlier than 10minutes before the first
bell. There is no supervision if the child arrives too early at the school in the morning.
2. Khalsa School has a closed campus policy. This means students must remain on the school grounds from the time they arrive
until dismissal at the end of the school day. Students must stay at the school for the lunch period. If students leave the
premises without prior approval, he or she will be suspended.
3. Students who are late in the morning must report to the office for a late slip.
4. Visitor/parents who come to Khalsa School must check in at the office upon arrival and have permission to enter the
premises.
5. All students, guests and staff are required to wear a head covering at all times, even during physical education activities.
6. The Gurdwara is a place for reverence and students are expected to show the utmost respect.
7. Move quietly in hallways, always using the right side, and only use those hallways/stairs assigned to each grade.
8. All lunches and snacks must be vegetarian (no meat, fish or eggs).
9. Report to a supervising teacher about any situation, which you consider dangerous to yourself or others.
10. If you are assigned a locker, you are responsible to take care of it. Lockers will be and can be inspected from time to time by
administration or teachers.
11. While travelling in our school buses, students must always remain seated, talk softly, keep their hands inside the bus and
follow all safety rules. Students may not bring hockey sticks on the bus. Any infraction of these rules will lead to suspension
of bus service to the student.
12. Bus students are advised that the buses have set schedules to meet both coming to and leaving school. Therefore, if you are
late, the bus drivers will be unable to wait for you.
13. Gum chewing is not permitted on the buses or at School.
14. Items not allowed at school or in school buses; PSP’s, DVD player, Game Boys, Nintendo DS, I pods, MP3 players, cell
phones, skateboards, any type of skates, play guns (including water guns), liquid paper, or gum etc. If confiscated, no item
will be returned.
15. All bikes must be locked and placed in a bike rack. Bikes are not to be used until school is dismissed.
1116. Rules regarding school uniform are given below and must be followed, they are as follows:
The regular school uniform is required while travelling to and from School, throughout the School day and for Field Trips,
unless otherwise specified in writing from the administration. Shirts must always be completely tucked into your pants.
The head covering must come across the forehead; no hair is to be showing in the front. If a female is wearing a dupatta, she
must also wear a rumal.
Female students must wear their hair in one or two braids only or a Jura on top of their head.( No pony tails, no loose hair)
Only a plain white shirt under the uniform can be worn.
No jackets can be worn in the Gurdwara or the classroom.
During lunch time, Khalsa School Gym strip may be worn if desired, and is required during gym periods; no other PE clothes
allowed. Shorts are not allowed.(except sports league tournaments)
Khalsa school uniform must be worn on all FIELD TRIPS.
Items not permitted: nail polish, make up, lipsticks, rings, necklaces, earrings, vests, flairs, jeans, baseball caps, shorts,
tearaways or another personal item that are not permitted under the uniform.
Amrit Dhari students must wear the five K’s.
Check School Uniform information for more detail.
THIS IS NOT AN EXHAUSTIVE LIST OF SCHOOL RULES. ANY BREACH OF GOOD MANNERS OR OF DISCIPLINE IS A
BREACH OF SCHOOL RULES.
Dear Parents,
Please discuss the Code of Conduct with your child. Please make sure that it is understood so that there will be no misunderstandings.
Thank you for your co-operation.
Parent/Legal Guardian’s Signature_______________________________ Date ______________________________
Parents Name: ____________________________________________
Student Signature __________________________________ Date_______________________________
Student’s Name (Please Print): ______________________________________
12Permission Letter for Publication of Students’ Work or Photographs on Websites
Dear parent or caregiver
I am writing to request your permission for photographs of your child to be taken during school activities. If photographs are taken,
this would be for the purpose of educating students, promoting the school, or promoting education. I am also seeking your permission
for the school to publish photographs, samples of your child’s work and also for broadcasting over television/ radio media or prepare a
CD/DVD of your child’s activities related to education.
If you give your permission, the school may publish photographs of your child and/or samples of work done by your child in a variety
of ways. The publications could include, but are not limited to, school newsletters (online and in hard copy), Khalsa School Internet or
intranet websites, school annual magazines and local newspapers. If published, third parties would be able to view the photographs
and work.
If you sign the attached form it means that you agree to the following:
1. The school is able to publish photographs of your child and samples of your child’s work as many times as it requires in the ways
mentioned above.
2. Your child’s photograph may be reproduced either in colour or in black and white.
3. The school will not use your child’s photograph or samples of your child’s work for any purpose other than for the education of
students, or for the general promotion of education and the school.
Any photographs taken by the school will be kept for no longer than is necessary for the above-mentioned purposes and will be stored
and disposed of securely.
Whilst every effort will be made to protect the identity of your child, Khalsa School cannot guarantee that your child will not be able
to be identified from the photograph or work.
If you agree please complete the consent form.
This consent, if signed, will remain effective until such time as you advise the school otherwise.
Consent Form for Publication of Students’ Work or Photographs
I agree, subject to the conditions set out above, to the taking of photographs of my child during school
activities, to be used by the school in educating students and promoting the school and public
education. I also agree to the publication of photographs or samples of work of my child. I will notify the
school if I decide to withdraw this consent.
Please circle one:--- yes or no
Student’s name: _______________________________________________Student’s Grade: __________
Signature of parent/caregiver: __________________________________Date: _____________________
Signature of student: _________________________________________Date: _____________________
1314
STATUS OF PARENT/GUARDIAN (ADMISSION TO CANADA AND RESIDENCY) – FORM A
(If parents are deceased, use form B)
Student’s Name: _________________________________________________________ Grade _____
Last name First name
To be completed and signed by a parent or legal (court-appointed) guardian. (If legal guardian, attach copy of court order appointing you as legal
guardian).
(Lawfully Admitted into Canada)
1. I am (please X one):
A Canadian citizen (if not born in Canada, please attach a photocopy of citizenship paper/card)
A Permanent Resident (landed immigrant) (attach photocopy of landed immigrant status paper or PR card)
Lawfully admitted into Canada under the Immigration and Refugee Protection Act (Canada) with one of the following
documents (please mark the appropriate box below and attach photocopy of document):
Admission as a refugee or refugee claimant
Valid student permit for two or more years (or issued for one year but anticipated to be renewed for one or more
additional years)
Valid employment authorization (work permit) for two or more years (or issued for one year but anticipated to be
renewed for one or more additional years)
A person carrying out official duties under the authority of the Visiting Forces Act or as an accredited diplomatic agent,
preclearance officer, consular officer or official representative in Canada of a foreign government with a consular post in
British Columbia.
Other – Document description: (must be cleared with Citizenship and Immigration
Canada____________________________________________________________
__________________________________________________________________
(Residency in British Columbia)
2. I am resident of British Columbia(please X one):
Yes Residency address: ________________________________________________
________________________________________________________________
________________________________________________________________
No I am not a resident of British Columbia
Confirming signatures:
3. Parent/Legal Guardian’s name: ___________________________________________________________
Parent/Legal Guardian’s signature: ___________________________________________________________
15Date: ___________________________________________________________
STATUS OF DECEASED PARENT (ADMISSION TO CANADA AND RESIDENCY) – FORM B
Student’s Name: _________________________________________________________ Grade _____
Last name First name
To be completed and signed by the student or a knowledgeable adult (one who knew the student’s parent(s) and has knowledge of the facts
respecting their decease and the matters set out in this document)
(Deceased parent was Lawfully Admitted into Canada)
1. The student’s deceased Parent was at time of death:
A Canadian Citizen
A Permanent Resident (landed immigrant)
(Deceased parent was Resident in British Columbia)
2. The student’s deceased parent was at time of death a resident of British Columbia (please X one)
Yes Residency address: ________________________________________________
________________________________________________________________
________________________________________________________________
No I am not a resident of British Columbia
Confirming signatures:
Student:_______________________________________________________
Knowledgeable Adult’s Name: _________________________________________________________
Knowledgeable Adult’s Signature: ______________________________________________________
(Knowledgeable Adult is one who knew the student’s parent(s) and has knowledge of the facts respecting their decease and the matters set out
in this document)
Date: __________________________________________________
16HEALTH HISTORY REQUEST
Please COMPLETE and RETURN this form to the school or your local health unit.
This information will be used to assess the immunization status of the school population.
RECORD OF IMMUNIZATION
CHILD’S NAME: SURNAME GIVEN NAME(S) BIRTH DATE: CARE CARD NUMBER
YYYY MM DD (PHN)
PARENT/GUARDIAN PHONE (HOME) PHONE (OTHER)
ADDRESS CITY POSTAL CODE
PREVIOUS ADDRESS (within last 5 years). Needed to request health unit records. CITY/PROVINCE/COUNTRY
SCHOOL ATTENDING IN SEPTEMBER GRADE PREVIOUS SCHOOL CITY
**Please attach a COPY of immunizations OR fill in the DATES of all past immunizations below**
DPTP-Hib MMR Hepatitis B MeningococcalC Pneumococcal Varicella
(Diphtheria, (Measles, Mumps, Conjugate Conjugate (Chickenpo
Pertussis, Tetanus, Rubella) x)
Polio, Haemophilus
Influenza Type B)
#1- #1- #1- #1- #1- #1
#2- #2- #2- #2- Age of
#3- #3- #3- Disease:
#4- #4-
DPTP –Kg Booster
(Diphtheria,
Pertussis, Tetanus,
Polio)
#5-
List any other immunizations received below or on the back of this sheet
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
______________
ATTENTION:
If your child has any condition which may affect school performance, limit activity or require emergency care (eg. Epilepsy,
diabetes, heart condition, asthma, severe allergy, etc.), it is the parents’ responsibility to inform the school and complete any
appropriate forms.
Signature of Parent/Guardian: Date Form Completed: Public Health Nurse:
Revised June 24, 2008
1718
Consent form
I consent to the following:
1. I agree to pay Tuition fees for the whole year regardless of whether I take the child out during the school year.
2. $ 20 will be charged for NSF cheque or two times credit card payment decline
3. I agree that all the fees are non- refundable.
____________________________________________
Parent’s Signature
____________________________________________
Parent’s Printed Name
_____________________
Date Signed
19KHALSA SCHOOL SURREY
6933 – 124 St. Surrey, B.C. V3W 3W6
Telephone: 604-591-2248
Visa/MasterCard Pre-authorization payment form
Campus: Newton /Old Yale Road/ Khalsa Secondary School
Customer Information:
Name of Card holder: ______________________________________________
Address: _________________________________________________________
Telephone: _______________________________________________________
Visa/M/C Number: __________________________________________________
Expiry date: ________________________________________________________
Child/Children name & Grade: __________________________________________________
Pay to the account of Khalsa school Surrey: School fee: $______Bus fee $________
Payment frequency (Yearly/ Term Wise) _____________
Next payment due: January / April
All authorized signature required:
Customer Signature:_____________________Date:_____________________
Customer signature: ____________________ Date: _____________________
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