Manitoba First Nations School System

Manitoba First Nations Education Resource Centre Inc.

Private Home Placement Application

All fields must be filled out completely with current contact information. A copy of the student
identification is required for verification(eg: birth certificate, baptismal, passport, etc )
This form is intended for parents to apply for students.
Once you apply and are approved for one program, you will be able to log into your parent/student portal for future registration applications.
Community*
School*
Academic Year*

Student Information

Last Name
First Name
Middle Name(s)
Date of Birth calendar
Common First Name Preferred
Alias/Other
Gender
First Nation Community
Treaty Number (Full 10 digits)
MET Number
*If MET# is unknown, enter a 9-digit # using DOB plus a digit (example: 3ddmmyyyy)
Current Address
Suite/Apt #, House #, Street Name, PO Box
City
Province
Postal Code
Email
Cell Number
For EFT Payments: Please provide your banking information and email
Is Student in care of Child & Family Services?
Are there any protection orders?
Are there any custody orders?
Are there any probation orders?
Does student require Judicial Services and Supports?

Education Information

Last School Attended
Location
Last Grade
Registered to Attend
Location
Current Grade
Start Date calendar
Are second level services required? Eg.(Physical, behavioural, learning, etc)

Medical Information

Medical Number (6 digit)
Medical Number (9 digit)
List any medical conditions or food allergies
Family Doctor's Name
Family Doctor's Phone Number
Emergency Contacts (Please provide 2)
Name
Relationship
Emergency Number
Name
Relationship
Emergency Number

Parent/Guardian Information

Parent/Guardian 1
Relationship
Last Name
First Name
Suite/Apt #, House #, Street Name, PO Box
City
Province
Postal Code
Email
Cell Number
Home Number
Work Number
Parent/Guardian 2
Relationship
Last Name
First Name
Suite/Apt #, House #, Street Name, PO Box
City
Province
Postal Code
Email
Cell Number
Home Number
Work Number

Home Placement (Please indicate Home Placement Preferences)

First Choice
Full Name
Relationship (Aunt, Friend, etc)
Suite/Apt #, House #, Street Name, PO Box
City
Province
Postal Code
Email
Cell Number
Home Number
Work Number
Alternative Choice
Full Name
Relationship (Aunt, Friend, etc)
Suite/Apt #, House #, Street Name, PO Box
City
Province
Postal Code
Email
Cell Number
Home Number
Work Number

Education Goals

Students are requested to submit information on their future education and career goals and areas of interest. This will aid the course selection and registration process to ensure students are enrolled in the correct courses. Email to:

Secondary Student Application Agreement

I understand the following conditions will apply for sponsorship by Manitoba First Nations School System(MFNSS).

1.To abide by PHP Student Policy Handbook that is provided.
2.To consult with the PHP coordinator and counselor if any problem arise, academically, emotionally, physically, and financially.
3.To accept responsibility for satisfying the academic requirements of the above institution.
4.To remain on PHP the student must attend classes and earn credits in each semester of the current school year.
5.Parents/Guardians are to remain residents of my home community during the school year (Sept-June).
6.I will adhere to the best of my abilities to the policies governing my sponsorship.

1.The above information is true to the best of my knowledge and I agree to the conditions 1-6 as outlined in the application.
2.I will sign and submit a Release of Information form to MFNSS.

Authorization of Student/Parent or Guardian

I hereby make application for financial assistance to enroll in a high school at an institution for which I have been accepted.

Name of Student
Date calendar

I hereby make application for financial assistance to enroll in a high school at an institution for which I have been accepted.

Name of Parent/Guardian (If under 18)
Date calendar

I hereby make application for financial assistance to enroll in a high school at an institution for which I have been accepted.

Name of House Parent
Date calendar
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