Consents and Authorization under the Freedom

of Information and Protection of Privacy Act

Information

I am acting on behalf of another individual who is

a minor who is incapable of acting on her/his own behalf

Guardian Information

Last name

First Name

Last name

First Name

Student Information

Consent for Collection of Personal Information

List the personal information to be collected (e.g., date of birth, location of birth,
date of death, location of death).

by Name of teacher and school

Consent for Use of Personal Information

I consent to the use of the following personal information: Describe the personal
information

Name of school,
for the following purpose(s): Describe how the personal information will be
used.
by Name of teacher and school

Storage of Personal Information Outside of Canada

I consent to

the storage outside Canada

of the following personal information: Describe the personal information
by Name of teacher and school
Full Name

Signature

Date

The collection of personal information provided on this form is authorized under section 26 of the Freedom of Information
and Protection of Privacy Act for the purpose(s) set out below. Should you have any questions about the collection of this
personal information please contact:

pg. 1
August 2016