Citizenship and Citoyennet et PROTECTED WHEN COMPLETED - B

Immigration Canada Immigration Canada

PAGE 1 OF 2

CUSTODIANSHIP DECLARATION -
CUSTODIAN FOR MINORS STUDYING IN CANADA
STUDENT INFORMATION
Family name Given name(s) Citizenship Date of birth Sex
Y M D
Male Female

Name and address of school in Canada

Address where student will reside in Canada

PARENTS/GUARDIANS INFORMATION (Preferably from both parents/guardians)

Parent/Guardian 1 Parent/Guardian 2

Full name Family name Given name(s) Family name Given name(s)

Y M D Y M D
Date of birth

Home address

Telephone number

CUSTODIAN INFORMATION
Family name Given name(s) Status in Canada Date of birth
Canadian citizen or Y M D

Permanent resident
Home address Telephone no.

The application of the official seal below confirms that the notary public has received evidence that the custodian is a Canadian citizen or a permanent resident, is over 19 years of
age, and currently resides at the home address stated above.

I, (name of custodian), hereby solemnly declare that I will undertake the full custodianship for the

said student, (name of student), during his/her stay in Canada, while under the age of majority in
the province in which he/she resides. As a custodian, I have made the necessary arrangements for the care and support of the said student in place of the parents as appropriate.
By signing this custodian agreement, I certify that I reside within a reasonable distance of the student's intended residence and school and will be able to fulfil my obligations as a
custodian in the event of an emergency.

Year Month Day

Signature of custodian Date

Sworn before me at: (city), in the province of (province/territory), country (if applicable).

This day of (month), (year).

Signature of notary OFFICIAL SEAL OF NOTARY PUBLIC

(AUSSI DISPONIBLE EN FRANAIS - IMM 5646 F)

IMM 5646 (01-2015) E ALSO AVAILABLE ON CIC WEB SITE AT : http://www.cic.gc.ca
 Citizenship and Citoyennet et PROTECTED WHEN COMPLETED - B
Immigration Canada Immigration Canada
PAGE 2 OF 2

CUSTODIANSHIP DECLARATION -
PARENTS/GUARDIANS FOR MINORS STUDYING IN CANADA
STUDENT INFORMATION
Family name Given name(s) Citizenship Date of birth Sex
Y M D
Male Female

Name and address of school in Canada

Address where student will reside in Canada

PARENTS/GUARDIANS INFORMATION (Preferably from both parents/guardians)

Parent/Guardian 1 Parent/Guardian 2

Full name Family name Given name(s) Family name Given name(s)

Y M D Y M D
Date of birth

Home address

Telephone number

CUSTODIAN INFORMATION
Family name Given name(s) Status in Canada Date of birth
Canadian citizen or Y M D

Permanent resident
Current residential address Telephone no.

My/Our child will reside: with the appointed custodian, in the school dormitory, or

with another person: (please provide name and indicate relationship).

I/We, and (names of parents/guardians),

the parents/guardians of the said student, (name of student), hereby grant full custodianship to

(name of custodian), during the student's stay in Canada, while he/she is under the age of majority in the
province in which he/she resides. I have made the necessary arrangements for the care and support of the said student such that the custodian should act in the place of me/us,
the parents. By signing this custodian agreement, I/We affirm that I am/we are satisfied the above appointed custodian resides within a reasonable distance of my/our child's
intended residence and school and will be able to fulfil his/her obligations as a custodian in the event of an emergency.
Year Month Day Year Month Day

Signature of parent/guardian (1) Date Signature of parent/guardian (2) Date

Sworn before me at: (city), in the province of (province/territory), country (if applicable).

This day of (month), (year).

Signature of notary OFFICIAL SEAL OF NOTARY PUBLIC

(AUSSI DISPONIBLE EN FRANAIS - IMM 5646 F)

IMM 5646 (01-2015) E ALSO AVAILABLE ON CIC WEB SITE AT : http://www.cic.gc.ca