Change of Address/Custodian Form

Change of Address/Custodian Form
Please complete this form and return to International Office at [email protected].
For high school students: Please submit the form to the ISSSW at school.
____________
DATE:
YYYY / MM / DD
Student’s Name:
Last Name (Family Name)
Date of Birth:
First Name
Preferred Name
Current Burnaby School:
Grade:
YYYY / MM / DD
Student Cell Number:
E-Mail:
Parent Name:
Last Name (Family Name)
First Name
PARENT SIGNATURE:
Date:
YYYY / MM / DD
Change of Student Address:
Host family father/mother:
______
Last Name (Family Name)
Street Address
(
First Name
DOB (mm/dd/yy)
City
)
(
Home Telephone Number
Postal Code
)
______
Cell Number
Email Address
Relationship to Student:
______________________________________
Change of Responsible Person (Custodial Guardian):
I, parent of student, have authorized the following person to be my child’s custodian, who is over 25 years of age and is a
permanent resident of Canada or Canadian Citizen:
Last Name (Family Name)
First Name
DOB (mm/dd/yy)
_________________________
Citizenship
Relationship to Student
Street Address
(
)
Email Address
City
(
Province
Postal Code
)
Home Telephone Number
(
)
Cell Number
____________
Work Number
Change of Parent Address (Home Country):
Street Address
City
Province/State
(
Country
(
Postal Code
)
(
Work Telephone Number
)
Home Telephone Number
)
Cellular Telephone Number