ELIS Application Form

ELIS Application Form
The Early Learning Intensive Support (ELIS) is a program for young children who require intensive support to meet their potential. This application form is intended for families with children with intensive needs.

It is important for you to understand that submitting an application does not guarantee your child a spot in a program.

Students are eligible to begin PreK once they turn 3.

*The information provided will be used for the purposes of determining your child's eligibility to participate in the Early Learning Intensive Support (ELIS) Pilot Program.
* Following receipt of the application you will be contacted to gather additional information and discuss options for your child.
* Students who are accepted into the ELIS program may be offered a spot at a school outside of their catchment area.

*** Please note that transportation is the responsibility of the family.***

If you have any questions, contact the Early Learning Facilitator Laura Adrian
Application:
School Applying for:
Principal of School
example@example.com
School Where Child Will Attend Kindergarten
Previous School Attended:
Applying for ?
Child's Demographic Information:
Child's Legal First Name:
Child's Legal Middle Name:
Child's Legal Last Name:
Name Used (if different than legal name):
Date of Birth ( MM-DD-YYYY):

MonthDayYear
Date
Gender:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address:
Street Address
Apartment Number
P.O. Box Number
City / Town
Province
Postal Code
Land Location Address

Child's Citizenship:
First Citizenship:
Second Citizenship (if applicable)
Birth Country:
Resident Type
What is your child's first language:
What other languages are spoken in the home:
Country of Origin:
At what age did your child begin to speak their first language:
Translation services required:
If your child's first language is not English, at what age did they begin to speak English:

Parent(s)/Guardian(s) Contact Information
First Parent/Guardian Contact Information:
Name

First NameLast Name
Relationship to Child - please specify:
Parent/Guardian Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work / Other Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
First Parent/ Guardian's current address
Home Address:
Street Address
Apartment Number
P.O. Box Number
City / Town
Province
Postal Code
Land Location Address
Level of Education:
Email
example@example.com

Parent(s)/Guardian(s) Contact Information
Second Parent/Guardian Contact Information:

If there are no additional parents/guardians please leave this page blank and click next.
Name

First NameLast Name
Relationship to Child - please specify:
Parent/Guardian Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work / Other Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Second Parent/ Guardian's current address
Home Address:
Street Address
Apartment Number
P.O. Box Number
City / Town
Province
Postal Code
Land Location Address
Level of Education:
Email
example@example.com

Parent(s)/Guardian(s) Contact Information
Third Parent/Guardian Contact Information:

If there are no additional parents/guardians please leave this page blank and click next.
Name

First NameLast Name
Relationship to Child - please specify:
Parent/Guardian Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work / Other Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Third Parent/ Guardian's current address
Home Address:
Street Address
Apartment Number
P.O. Box Number
City / Town
Province
Postal Code
Land Location Address
Level of Education:
Email
example@example.com

Parent(s)/Guardian(s) Contact Information
Fourth Parent/Guardian Contact Information:

If there are no additional parents/guardians please leave this page blank and click next.
Name

First NameLast Name
Relationship to Child - please specify:
Parent/Guardian Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work / Other Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fourth Parent/ Guardian's current address
Home Address:
Street Address
Apartment Number
P.O. Box Number
City / Town
Province
Postal Code
Land Location Address
Level of Education:
Email
example@example.com

Custody Information
Child lives with (List all, specify):
At the time of the child's birth, were you or any of their parents / guardians a teenager?
Is the family experiencing financial need?
Is there a legal custody arrangement?
If yes, who has legal custody: (Please share legal documentation upon admittance to the program)

Daycare/Babysitter Contact:
Daycare or child care provider name:
Licensed:
Daycare/Babysitter Address:
Street Address
Apartment Number
City / Town
Province
Postal Code
Land Location Address
Daycare/Babysitter Primary Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Daycare/Babysitter Other Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Has your child been involved with other childcare programs (i.e. Daycare, Private Pre-school, Early Learning Centre, Head Start, etc.)
If Yes, Provide List:
Does your child receive Enhanced Accessibility Grant Funding?

Emergency Contact Information:
Who should be contacted in case of an emergency if parent(s)/guardian(s) cannot be reached?

(Emergency contact should be someone who is in close proximity to the school and can be contacted if the parents are unavailable)
First Emergency Contact Name

First NameLast Name
First Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
First Emergency Contact Relationship to Child
Second Emergency Contact Name

First NameLast Name
Second Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Second Emergency Contact Relationship to Child

Voluntary Indigenous Self Declaration:
Overview

Parent(s)/guardian(s) are asked to identify their children/students as being Indigenous (First Nations, Inuit, Métis), or of non-Indigenous ancestry, during the registration process. The choice to identify is voluntary and confidential.

Privacy

This information is stored electronically and in paper form, in the student’s cumulative file. It is secure and access is limited to HTCSD and the SK Ministry of Education. All employees within HTCSD are to adhere to “Local Authority Freedom of Information and Protection of Privacy (LAFOIP)”.

Why self-declare?

Some individuals may be hesitant to self-declare as an ethnic group member for fear of being marginalized or because of past experiences. Information on a self-declaration form is used solely to help define programming and services to assist in the success and achievement of Indigenous students in and throughout their schooling experience.

The Canadian Constitution recognizes three distinct groups of Indigenous people.

First Nations / Registered / Treaty / Status (refers to an individual recognized by the federal government as being registered under The Indian Act)

First Nations / Non-Registered / Non-Status (refers to a First Nations person who is not registered under The Indian Act)

Métis (refers to a person of mixed First Nations and European ancestry who identifies as Métis, as distinct from First Nations, Inuit, or non-Aboriginal)

Inuit (refers to a person who identifies as Inuit, as distinct from First Nations, Métis, or non-Aboriginal)
Please Select an Option Below:

Siblings:
Does this child have a sibling who currently or will be attending school?
If Yes, please list sibling(s) name(s), age(s), and school(s) they attend:

Please outline the strengths and needs of your child in the following areas:
Mobility: Describe how your child moves from one place to another:
Lifting required?
Weight of child: (indicate lb or kg)
Physical development (like running and jumping, holding a crayon, catching a ball or using a spoon)
Medical Needs: (eg. oxygen, g-tube fed, seizures? etc.)
Sensory Needs: (sounds, lighting, touch, smell, etc.)
Is there anything else you would like to share about your child and/or family?

Religion:
Parent / Guardian 1 Religion / Spirituality
Parent / Guardian 2 Religion / Spirituality
Parent / Guardian 3 Religion / Spirituality
Parent / Guardian 4 Religion / Spirituality
Student Religion / Spirituality
If neither parents nor student are Catholic, please acknowledge the following: In accordance with Administrative Procedure 300: Admission of Students, I wish to have my child/children attend a Catholic school. My child is not Catholic but an important reason why I am choosing a Catholic school is to have my child/children participate in the spiritual formation and atmosphere that Catholic schools provide. I agree to comply with and support, to the best of my ability, the vision, mission, and covenant of shared values of the school division, the religious education program, and the religious celebrations of the Catholic school, excluding reception of the sacraments. I am aware that if I am not Catholic I am unable to run for the HTCSD Board of Education.
I agree with the above statement.

Consent and Release Form
Consent to Exchange Information

I hereby consent to the release of information to the Prekindergarten Selection Committee for any agency, I have identified in this application that pertains to my child's eligibility for enrolment in the Prekindergarten program at Holy Trinity Catholic School Division.

I understand that the information contained in this application will be held in confidence by the Prekindergarten Selection Committee.
Declaration:

I, the undersigned, hereby represent that I have the legal authority to apply for this child. I declare the information that I provided on this form is complete and accurate. I will notify the school of any changes to the information on this form.

Name of person submitting application:
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

ELIS Application Form

Application:

Child's Demographic Information:

Child's Citizenship:

Parent(s)/Guardian(s) Contact Information

Parent(s)/Guardian(s) Contact Information

Parent(s)/Guardian(s) Contact Information

Parent(s)/Guardian(s) Contact Information

Custody Information

Daycare/Babysitter Contact:

Emergency Contact Information:

Voluntary Indigenous Self Declaration:

Siblings:

Health History:

Early Learning Behaviours and Experiences:

Speech:

Please outline the strengths and needs of your child in the following areas:

Service Providing Agencies:

Religion:

Consent and Release Form