STUDENT APPLICATION FORM

STUDENT INFORMATION

Representative agency: ____________________________________________________________________________

INTERNATIONAL EDUCATION SCHOOL DISTRIC 42

Program Start date: ________________________ End date: ____________________

Family name: _____________________________________________________________________________________

VILLAGRAN HERNANDEZ

First name: _______________________________________________________________________________________

MICHELLE GABRIELA

English name (if any):_______________________________ Language in the home: ____________________________

SPANISH

Date of birth: day ________

08 month ________
JULY year ____________
1981 Gender: ☐ Male ☐ Female
✔

Street Address: ____________________________________

AVENIDA LA CALMA 3416-8

City: _____________________________________________
ZAPOPAN Province/State: JALISCO
________________________________

Country: MEXICO
__________________________________________ Postal code: 45070
__________________________________
Home telephone: ___________________________________ Student’s email: _______________________________
NONE michelle.villagran@tepeyac.mx

Father’s full name: LUIS

___________________________________________
MARIO VILLAGRAN E INCHAUSTEGUI Date of birth: _______________________
JANUARY 8 1947

Work telephone: 0018317475608

_____________________________________Email: _______________________________________
luis,villagran@yahoo.com

Mother’s full name: RUTH

__________________________________________
NOEMI HERNANDEZ CARRILLO Date of birth: _______________________
MAY 10 1682

Work telephone: _____________________________________Email:

3221498925 ________________________________________
ruthy_v@hotmail.com

List siblings, if any, with ages: ________________________________________________________________________

IN CASE OF EMERGENCY PLEASE CONTACT MY HUSBAND: IZEF GARCIA--CELLPHONE 8115908905

MEDICAL INFORMATION

Do you have any allergies? ☐ Yes ☐

✔ No

If yes, please describe: _____________________________________________________________________________

Do you have any ongoing health concerns? ☐ Yes ☐

✔ No

If yes, please describe: _____________________________________________________________________________

Do you regularly take medication? ☐ Yes ☐

✔ No

If yes, please list here: ____________________________________________________________________________

 SD42 Cultural Program Consent Form

Dear Parent:

Your son or daughter is participating in the SD42 Cultural Program. This is a program designed around indoor and
outdoor activities which could include activities such as listed below. For a complete list of activities included in your
child’s program, please refer to their program schedule.

Indoor rock climbing Tour of the University of British Columbia

Vancouver seawall walking next to the ocean Outdoor hiking at Grouse Mountain
Paddle voyageur canoes on Alouette lake Visit to Whistler Mountain
Walk trails and suspension bridge at Lynn Canyon Windsurfing at Jericho Beach in Vancouver

These activities will include a range of physical activities, from relatively easy to fairly strenuous.

Transportation to and from activities will include use of school buses and travel on BC Ferries.

Instructors will carry certified First Aid Kits on all trips and have their First Aid Training and Certification.

Your child will not be supervised by an adult at all times. Students need to be aware that normal school rules will apply
at all times. Student and group safety is the number one priority and all students must adhere to the program rules.

Accidents can be the result of any type of activity, and can occur with or without any fault on either the part of the
student or the School Board or its employees, contractors or agents of the facility where the activity is taking place.
By allowing your child to participate in this program and described activities, you are accepting the risk of an accident
occurring and agree that the activities, as described above, are suitable for your child.

Inherent risks are as follows:

 Travel to and from the field trip site  Injury from falling rock or branches
 Inclement weather  Drowning
o
 Injury from falls or trips while hiking  Sunstroke/heat
o exhaustion
 Attack by animals  Dehydration
o
 Hypothermia from cold/rain  Failure to follow instructions of the
teacher/instructors
I hereby give my consent , and acknowledge by my signature that my child,
Please indicate by a  that
may attend the SD42 Cultural Program
you have read and
being offered from understood each section.

On these fieldtrips, from 10 to 30 students will be in attendance, depending on the

nature of the activity.
The students will be supervised by at least 1 staff plus other supervisors as needed.
Your child will not be directly supervised by an adult at all times.

My child has no illnesses, allergies or disabilities that may require special attention, except as

✔
described here:

Medications that my child will have in their possession are:

Accidents can be the result of the nature of the activity and can occur with or without any

✔
fault on either the part of the student, or the school board or its employees, contractors or
agents, or the facility where the activity is taking place. By allowing your child to participate
in this activity, you are accepting the risk of an accident occurring, and agree that this activity
as described above, is suitable for your child.

In signing this Consent, I am not relying on any oral or written representation or


✔
statements made by the School Board and its agents, employees, or authorized volunteers,
or the Ministry of Education, to induce me to permit my child to take the trip, other
than those set out in this Consent.

I am 19 years of age or more and have read and understand the terms of this consent and
waiver, and understand that is binding upon me, my heirs, executors and administrators. 
✔

Signature of Parent Printed Name of Parent

JANUARY 18TH, 2019

Date