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PORTAGE LA PRAIRIE SCHOOL DIVISION
535 THIRD STREET N.W., PORTAGE LA PRAIRIE, MANITOBA R1N 2C4
TELEPHONE 204-857-8756 FAX 204-239-5998
FOREIGN STUDENT REGISTRATION

This form is to be completed prior to the first day of attendance for students new to the division. Eligibility to attend school in the Portage la Prairie School Division requires a formal written agreement with the division which authorizes eligibility.
(Este forma estrara completado antes del dia primerode attendencia por los estudiantes nuevos a la division. Elegibilidad para atendar los escuealas de la division de Portage la Prairie necesita un contrato formal y escribado con la division que dan permision)

Legal Name of Student (Nombre del estudiente)	__________________________ last first middle (apellido nombre completo)	Date of Birth (Fecha de Nevidad)	_____________ yy mm dd ano mm dd
Residence Address (Direccion de la residencia)	__________________________ __________________________	City/Town (Ciudad/pueblo)	_____________
Nationality (nationalidad)	__________________________	Interests/Hobbies (diversiones)	_____________
Last School Attended	__________________________	Grade Level (Nivel de escuela)	_____________
Father’s Name (nombre del padre)	__________________________	Mother’s Name (Nombre de la madre)	_____________
Home Telephone (Numero de telefono de la casa)	__________________________	FAX	_____________
Emergency Contact Person (Contacto emergencia)	__________________________	Relationship (relacion)	_____________
Home Telephone (Numero de telefono en casa)	__________________________	Work Telephone (numero de telefono en trabajo)	_____________

MEDICAL INFORMATION
(Informacion Medico)
Please list any special medical needs (Por favor hace una lista de las necesidades medicos)_______________________________________________________________

Please list any allergies the student may have (e.g. Penicillin, food, animals, other drugs) Please explain. (For favor hace una lista de las alergias que el estudiente tiene (ejemplo: penicilina, comida, animales, otras medicias) ______________________________________________________________________________________________________

PROGRAM INFORMATION
(Informacion del programa)

Starting Date _________________ Finishing Date _________________ Number of Weeks ___________________
(Fecha de comenzando) ( Recha de completando) (Cuantos semanas)

Semester(semestre):   1            2

I am planning to extend for the next semester: yes/si        no
(tengo planes a continuar el semestre proximo)

Do you require the school division to assist you in making homestay arrangements? yes/si         no
(Necesita asistencia de la division de la esucala para obtenir una casa para vivir)

If yes (Si si):
Do you smoke?     yes/si         no
(Fuma)

Do you like pets? yes/si         no
(Se gustan los anuimals de la casa)

Placement Preferences (Preferencias por la colocacion)

    Family with young children: yes/si        no
    (Familia con los ninos)

    Teenagers: yes/si         no
    Chicos

    Adults with no children: yes/si         no
    (Adultos sin hijos)

BD 23-98/05

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