Victory Hill Dorm Application (CF4077)

Victory Hill Dorm Application

The personal information collected on this form will be used for the purpose of service plan and evaluation and will be treated confidentially in compliance with the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information please contact the Director, Provincial Deaf and Hard of Hearing Services at (604) 660-1800 (voice), (604) 660-1807 (TTY), 4334 Victory St, Burnaby BC, V5J 1R2.

Child/Youth

Last Name

First Name

Middle Name

Preferred Name

Country of Birth

Date of Birth (MM/DD/YYYY)

Gender

Aboriginal/Indigenous and Status Number

Child/Youth Cell Phone (555) 555-5555

Child/Youth E-Mail Address

Please attach a clear photocopy of your child/youth’s

Type of indentificaiton

Attach a clear photocopy of your child/youth’s:

Drag file here or select file.

Drag file here or select file.

Parent/Guardian Contact

Relationship to Child/Youth

Last Name

First Name

Address

City

Postal CodeUse the format: A1A 1A1

E-mail Address

Phone Number (555) 555-5555

Text/Cell Phone Number (555) 555-5555

Parent/Guardian Secondary Contact

Relationship to Child/Youth

Last Name

First Name

Address

City

Postal CodeUse the format: A1A 1A1

E-mail Address

Phone Number (555) 555-5555

Text/Cell Phone Number (555) 555-5555

Alternate Placement

To provide care to your child on weekends when he/she is not able to travel home due to poor weather conditions or

other emergencies.

Relationship to Child/Youth

Last Name

First Name

Address

City

Postal CodeUse the format: A1A 1A1

E-mail Address

Home/Work Number (555) 555-5555

Cell Phone Number (555) 555-5555

Family Doctor

Name

Office Name

Address

City

Postal CodeUse the format: A1A 1A1

Office Phone Number (555) 555-5555

Fax Number (555) 555-5555

Alternate Number (555) 555-5555

Clarification of Guardianship and Visiting Rights

If someone plans to visit your child/youth at VHD, please communicate with the VHD Manager to confirm approval.

Please fill in for persons NOT PERMITTED visits/contact with your child/youth

Last Name

First Name

Relationship

Reason for no contact

Declaration

Information provided on this form

I confirm the information I have provided is true and complete

Technology Access and Use Agreement

I, the undersigned, have read the Technology Access and Use Policy and Regulation and agree to the provisions therein. I understand that computer and network services are intended for educational purposes and are a privilege.
I understand that it is my responsibility to:

a. Instruct my child/youth regarding any additional boundaries of what is considered acceptable use by members of our family.

b. Be aware of the risks in accessing the Internet.

c. Emphasize to my child/youth the importance of personal safety in Internet use.

I understand that it is impossible for VHD to restrict access to all controversial and inappropriate materials and will not hold VHD responsible for material acquired through the student’s use of Internet access.
I give permission for my child/youth to receive access to Internet at the Victory Hill Dorm.

Media Release Waiver

Victory Hill Dorm (VHD) produces VHD internal newsletters, annual yearbook, reception TV screen, display walls in dorm

houses, and creates various videos and film projects. These resources are more effective when real people are featured

participating in and communicating about VHD. We hope you will permit us to use images of you and/or your child and

family. Written permission is required, thus please consider signing this Media Release Waiver to indicate your consent.

I hereby authorize and give my consent to Victory Hill Dorm to publish images of me or my child for the purpose of VHD resources.
I further agree that Victory Hill Dorm may use these images for publications and public displays (reception TV screen and display walls in dorm houses).

Allowance Waiver

Written permission is required for a child/youth to bring money from home or access a bank account close to Victory Hill

Dorm. Staff will not log purchases, keep receipts or cover shortage of money. E-transfer from parents to staff is not

permitted.

Do you give permission for your child/youth to manage their own allowance as part of developing independent skills, bring money from home, and access a bank account close to Victory Hill Dorm?

Consent

Parent/Guardian's Name

Date Signed (MM/DD/YYYY)

Parent/Guardian's Signature

By clicking submit you will sending your application electronically to the Victory Hill Dorm Manager.

If you prefer to print and mail your application, click the PDF button to generate a printable version.

Mail to:

Victory Hill Dorm, c/o Patrick Tarchuk

4334 Victory Street

Burnaby BC V5J1R2

Please mark the envelope CONFIDENTIAL.

Victory Hill Dorm Application