Email (leave empty if the same as the parent's)
Preferred Name
Date of birth
*
Country of birth
*
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Date of arrival to Canada
Dear Parent(s) , Information we collect is to facilitate child and youth development through the SWIS program at CVIMS in partnership with Nanaimo Ladysmith Public Schools and community partners, to make referrals to other service providers and for the administration of programs and services. A signed RELEASE OF INFORMATION form is a condition of eligibility for support services. Once signed and dated, this form shall remain in effect until your child is no longer enrolled in SD 68/69. You have the right to revoke this permission at any time by providing CVIMS with a written notice of termination.
*Personal information may include: name, address, phone number, email address or resume.
Name of individual giving consent
*
Relationship to youth
*
Date
*