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English Language Support Program (ELS) 2nd iteration

STUDENT REGISTRATION FORM

The English Language Support Program is a free after-school English program for newcomer children in grades 4-7 who are new to Canada from Ukraine, displaced by the war.

The program runs in-person at the Surrey City Centre Library every Saturday from 11:00 am to 1:00 pm. The Fall iteration of this program consists of 8 sessions, once a week, from October 21st to December 16th, 2023.

We have space for 15 children, on a first-come first-serve basis. If the program is full, you will be placed on a waitlist.

Please note:
1) Registration priority is given to Surrey residents, however, children from other cities may also apply. These students will be placed on the waitlist and invited to join the program if there is space available, after October 13th.
2) Students who previously participated in this program can register again, however, they will be placed on the waitlist and only invited to join the program if there is space available, after October 13th.

Program location: Surrey City Centre Library (10350 University Dr, Surrey, BC V3T 4B8)

Q1 . I understand that this program runs in-person at the Surrey City Centre Library every Saturday from 11:00 am to 1:00 pm and confirm that my child will be present at all the sessions (if child is sick please notify us in advance)

Yes

Q2 . Student's Information

Student's First Name :	*
Student's Last Name :	*
Student's Birthdate (month/day/year) :	*
Student's Age :	*
Name of Student's School :	*
Language(s) Student Can Speak and Read in :	*

Q3 . Student's Gender

Q4 . Home Address (number, street, city, province and postal code)

Q5 . Parent / Guardian's Information

First name :	*
Last name :	*
Phone number (home or cell) :	*
Email :	*
First name (if more than one parent/guardian) :
Last name :
Phone number (home or cell) :
Email :

Q6 . Background Information

Has the family recently settled in Canada from Ukraine? (Yes/No) :	*
How long has the family been living in Canada? :	*

Q7 . Student's Health

Student's Allergies and/or Dietary Restrictions :	*
Student's Medications and Important Medical Information :	*

Q8 . Emergency Contact's Information

First and Last Name (Must be different from "Parent/guardian" info provided above) :	*
Relationship to Child :	*
Phone Number (cell or home) :	*

Q9 . Dismissal Information (please check one):

My child has permission to walk home alone.

My child will be picked up after each session by the following designated people:

Q10 . Person 1 (who can pick my child up)

Name :
Relationship to child :

Q11 . Person 2 (who can pick my child up)

Name :
Relationship to child :

Q12 . Person 3 (who can pick my child up)

Name :
Relationship to child :

Q13 . How did you hear about this program?

SFU website

Library website

Friend referral

SFU staff referral

City Centre Library referral

DIVERSEcity referral

Elementary or high school staff referral

Other

* My child has participated in this program before.

Q14 . If you selected "Other" above, please specify: