Current Page 1 Page 2 Page 3 Preview Personal information and personal health information will be collected by the Student Well-being Team for the purpose of providing students with appropriate services. Personal information is collected under the authority of the Freedom of Information and Protection of Privacy Act section 31(c). Personal health information is collected under the authority of the Health Information Act section 17(1). If you have any questions, see a Student Well-being Team member or contact the Student Well-being Team Program Lead at 16 Fitzroy Street, Charlottetown, PE, Canada, C1A 7N8 or call 902-368-5868. Identification Provide information about the student in the fields below. Student First Name Student Middle Name Student Last Name Student Address 1 Student Address 2 Student City, Town, or Community Student Postal Code For example C1B 0X1 or 12345 Student Cell Phone For example 902-555-5555 Date of Birth Personal Health Number (PHN) Please enter the 8-digits from the student's PEI health card. Primary Language Spoken at Home - None -EnglishFrenchOther Other Language Does the student go to a public school? - Select -YesNo What public school does the student attend? - Select -Alberton Elementary SchoolAmherst Cove Consolidated SchoolAthena Consolidated SchoolBelfast Consolidated SchoolBirchwood Intermediate SchoolBloomfield Elementary SchoolBluefield High SchoolCardigan Consolidated SchoolCentral Queens Elementary SchoolCharlottetown Rural High SchoolColonel Gray Senior High SchoolDonagh Regional SchoolEast Wiltshire Intermediate SchoolÉcole ÉvangélineÉcole François-BuoteÉcole La-Belle-ClocheÉcole Pierre-ChiassonÉcole St-AugustinÉcole-sur-MerEliot River Elementary SchoolEllerslie Elementary SchoolElm Street Elementary SchoolEnglewood SchoolGeorgetown Elementary SchoolGlen Stewart Primary SchoolGreenfield Elementary SchoolGulf Shore Consolidated SchoolHernewood Intermediate SchoolJohn J. Sark Memorial SchoolKensington Intermediate Senior High SchoolKinkora Regional High SchoolL.M. Montgomery Elementary SchoolM.E. Callaghan Intermediate SchoolMiscouche Consolidated SchoolMontague Consolidated SchoolMontague Intermediate SchoolMontague Regional High SchoolMorell Consolidated SchoolMorell Regional High SchoolMount Stewart Consolidated SchoolO'Leary Elementary SchoolParkdale Elementary SchoolParkside Elementary SchoolPrince Street Elementary SchoolQueen Charlotte Intermediate SchoolQueen Elizabeth Elementary SchoolSherwood Elementary SchoolSomerset Elementary SchoolSouris Regional SchoolSouthern Kings Consolidated SchoolSpring Park Elementary SchoolSt. Jean Elementary SchoolSt. Louis Elementary SchoolStonepark Intermediate SchoolStratford Elementary SchoolSummerside Intermediate SchoolThree Oaks Senior High SchoolTignish Elementary SchoolVernon River Consolidated SchoolWest Kent Elementary SchoolWest Royalty Elementary SchoolWestisle Composite High SchoolWestwood Primary School What school outside of the public school system does the student attend? For example, Grace Christian School, the Mount Academy, home education, or not enrolled in school. Grade - Select -Kindergarten Grade 1Grade 2 Grade 3 Grade 4Grade 5Grade 6 Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12 Specify any physical, mental, cognitive, developmental, or medical conditions/diagnoses that the student well-being team should be aware of. Specify any allergies that the student well-being team should be aware of. Requires an Epi-Pen for use at school Life-threatening allergy Other allergies Life-threatening allergies (specify) Other allergies (specify) Who is filling out this form? - Select -StudentParent/GuardianTeacherPrincipalStaff MemberSchool CounsellorService ProviderCommunity MemberOther What is the name of the service? Email Address A confirmation email for this form will be sent to the address provided. Applicant Information First Name Last Name Telephone Number For example 902-555-5555 Relationship to Student