Student Well-being Team Referral Form | eServices Prince Edward Island

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

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

Gender

Other Gender

Personal Health Number (PHN)

Please enter the 8-digits from the student's PEI health card.

Primary Language Spoken at Home

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

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?

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