Student & Parent/Guardian Information

STUDENT*

First Name

Surname

School Grade in 2022/23

Greek Class Level

Student's Date of Birth*

day

month

year

PARENT(S)/CAREGIVER(S)*

First Name

Surname

Phone #

Parent 1

Parent 2

Email address for confirmation email:*

Address information*

Street Address City State / Province / Region Postal / Zip Code Country

Student Media Release Consent

Part 1 - Events

I hereby agree and give my permission for the Mississauga Hellenic Academy (MHA), Ελληνικό Σχολείο / Greek School Program and/or partners to record, film, photograph, audiotape or videotape our/my child’s name, image, student work, and performance (hereinafter collectively referred to as “Works”) and to display, publish or distribute these Works for the purpose of publishing, posting on the website, posting in schools, posting on social media sites and/or for broadcasting on television or radio as determined by the MHA Organizing Parent Committee. I hereby waive any right to approve the use of these Works now or in the future, whether the use is known to me or unknown, and I waive any right to any royalties related to the use of these Works. I understand that the Works may appear in electronic form on the internet or in other publications outside of the MHA’s control. I agree that I will not hold the MHA responsible for any harm that may arise from such unauthorized reproduction.

Events*

Please mark this box if you AGREE that your child may participate in recorded MHA school events and MHA hosted events as described above. (See Part 2 below)

Please mark this box if you DO NOT WISH your child to participate in recorded MHA/school events and MHA hosted events.

Part 2 - Media Specific

I also understand that external media organizations may attend school events. I give permission for our/my child’s name, image, student work, and performance to be photographed, filmed, audio-taped or videotaped for the purpose of being published and/or broadcast on-line, on television or radio.

Media Specific*

Please mark this box if you AGREE that your child may participate in media events that may be published or broadcast by organizations external to the MHA.

Please mark this box if you DO NOT WISH your child to be photographed, filmed, audio-taped or videotaped at media events.

Understand content*

I have read this Student Media Release Consent Form and I fully understand the contents and meaning of this release. I understand that I am free to contact the Principal/Site Supervisor with any questions regarding this release.

Medical Information

The collection and retention of the information requested on this form is authorized and governed by the Ontario Education Act and the Municipal Freedom of Information and Protection of Privacy Act. The following information will be helpful to the teacher in making your child/ward comfortable and safe.

Family Physician's Name

Title

First

Last

Family Physician's Phone Number

Ontario Health Card #*

Please provide details of usual treatment for each of the conditions indicated

Please explain if your child/ward has any medical condition that requires any modification of his/her program

PLEASE LIST ALL KNOWN ALLERGIES TO THE FOLLOWING:

Food Allergies

If foods are life-threatening, please explain the symptoms and the treatment:

Medication Allergies

Other Allergies (e.g., bee or wasp stings, environmental allergies)

Has your child suffered any serious allergic or asthmatic reaction? *

Yes

If so, please provide details, including the type and severity of reaction:

Has a doctor prescribed an Epi-Pen for your child?*

Yes

Has a doctor prescribed an inhaler for asthma?*

Yes

Has a doctor prescribed an inhaler for any other reason?*

Yes

DIETARY RESTRICTIONS

Please list any foods your child should not eat for medical, dietary, or religious reasons

MEDICATION

Does your child/ward take prescribed medication on a regular basis?*

Yes

If yes, please specify

GENERAL

Does your child wear or carry medical alert identification (e.g., bracelet)?*

Yes

If yes, please specify what is written on it

Does your child have any other relevant medical condition that will require modification of the program?*

Yes

If yes, please explain

Does your child have any special fears or conditions (e.g., anxiety, bed-wetting, and nightmares), the knowledge of which will allow the teacher to make the student more relaxed?*

Yes

If so, please explain

Should it become necessary for my child/ward to have medical care, I hereby give the MHA teacher permission to use her/his best judgment in obtaining the best of such service for my child. I also understand that in the event of such illness or accident, I will be notified as soon as possible.*

I consent

Payment

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