1 Current Page 1 2 Page 2 3 Page 3 4 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 Date of Birth Gender - None -FemaleMaleUndisclosedOther Other Gender 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 Name of School For example: Bloomfield Elementary School, Colonel Gray Senior High School, École François-Buote, Immanuel Christian School, home-schooled, etc. 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 ProviderOther 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