Registration for Gifted Program

* - Required field

A. Student Information
*Start Date	Immediate September Other, please specify: Year201220132014Month123456789101112Day12345678910111213141516171819202122232425262728293031
*Legal Surname		Usual Surname
*Previous Surname(s) (Enter "none" if student does not have a previous surname)
*Legal FIRST Name		Usual First Name
*Legal MIDDLE Name	(Enter "none" if student does not have a middle name)	*Gender	Male Female
		*Date of Birth	Year193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012Month123456789101112Day12345678910111213141516171819202122232425262728293031
*Telephone - Home		Fax
Telephone - Work		*Student's Email	(Enter "none" if student does not have email)
*Resident of British Columbia?	Yes No	*Parent/Guardian Email	(Enter "none" if parent/guardian does not have email)
NOTE: Please make sure to include any PO boxes, suite #’s etc... or any information we will need to ship you materials.
*Home Address		Mailing Address (if different)
*City		City
*Province		Province
*Country		Country
*Postal Code		Postal Code
*First & Last name of Parent/Guardian	(Enter NA if not applicable)	*Relationship	(Enter NA if not applicable)
		Address & Phone if different from student's
First & Last name of Parent/Guardian		Relationship
		Address & Phone if different from student's
*First Nations, Metis, Inuit Aboriginal Ancestry?	None Status - On Reserve Status - Off Reserve Metis Inuit
*Are you currently taking a course at NIDES?	Yes No

I am remaining enrolled in another school.
*Name of school:
*Your current grade:	None K 1 2 3 4 5 6 7 8 9 10 11 12
I understand that my current school administrator must email the registrar to approve my course selection.

The Applicant confirms that the information in this form is accurate and complete, that the Applicant has the legal right to enroll the student in NIDES, and that the Applicant understands that no materials will be forwarded until fees and deposits (where applicable) are paid; that work required will be completed and returned as directed; and that enrollment remains valid for one year.	I agree
The Applicant confirms the legal guardian, student, and home facilitator’s commitments to working together with NIDES in completing the coursework agreed to by all parties during the normal academic calendar (unless otherwise negotiated). Working together is defined by consistent activity in courses (unless previously agreed to, consistent activity is defined as weekly submissions according to the personal education plan of the student) and continuous communication with the NIDES teachers (weekly).	I agree
The Applicant understands that if the student is inactive, he/she may be withdrawn from the course.	I agree
If using NIDES computers and/or online services, the Applicant agrees that the Internet access only be for educational and lawful purposes.	I agree
The Applicant hereby authorizes the release of all previous records to the North Island Distance Education School, and authorizes North Island Distance Education School to report to schools, school districts, or post-secondary institutions where records exist.	I agree
By completing this form and submitting it, it is assumed that the Applicant agrees to the above conditions of enrollment.	I agree

Questions/Comments: