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CUSTODIANSHIP DECLARATION CUSTODIAN FOR MINORS STUDYING IN CANADA
监护人声明 在加拿大学习的未成年人的监护人

STUDENT INFORMATION  学生信息

位于加拿大的学校名称与地址 Appleby College 540 Lakeshore Rd W Oakville， ON L6K 3P1
Name and address of school in Canada
Appleby College
540 Lakeshore Rd W
Oakville, ON L6K 3P1
Name and address of school in Canada Appleby College 540 Lakeshore Rd W Oakville, ON L6K 3P1| Name and address of school in Canada | | :--- | | Appleby College | | 540 Lakeshore Rd W | | Oakville, ON L6K 3P1 |

性 ◻ ◻◻ \square F 女 M 男 X 其他性别
Gender ◻ ◻ ◻\square F Female
M Male X Another gender
Gender ◻ F Female M Male X Another gender| Gender $\square$ F Female | | :--- | | M Male X Another gender |

学生在加拿大的居住地址 Appleby College 540 Lakeshore Rd W Oakville， ON L6K 3P1
Address where student will reside in Canada
Appleby College
540 Lakeshore Rd W
Oakville, ON L6K 3P1
Address where student will reside in Canada Appleby College 540 Lakeshore Rd W Oakville, ON L6K 3P1| Address where student will reside in Canada | | :--- | | Appleby College | | 540 Lakeshore Rd W | | Oakville, ON L6K 3P1 |
"Name and address of school in Canada Appleby College 540 Lakeshore Rd W Oakville, ON L6K 3P1" "Gender ◻ F Female M Male X Another gender" "Address where student will reside in Canada Appleby College 540 Lakeshore Rd W Oakville, ON L6K 3P1" | Name and address of school in Canada <br> Appleby College <br> 540 Lakeshore Rd W <br> Oakville, ON L6K 3P1 | | | | Gender $\square$ F Female <br> M Male X Another gender | | :--- | :--- | :--- | :--- | :--- | | Address where student will reside in Canada <br> Appleby College <br> 540 Lakeshore Rd W <br> Oakville, ON L6K 3P1 | | | | |
PARENTSIGUARDIANS INFORMATION (Preferably from both parents/guardians)
父母 i 监护人信息（最好来自父母/监护人双方）
Parent/Guardien 1  家长/Guardien 1 Parent/Guardian 2  家长/监护人 2
Full name  全名
  姓 Shen
Family name
Shen
Family name Shen| Family name | | :--- | | Shen |
  姓氏：周
Family name
Zhou
Family name Zhou| Family name | | :--- | | Zhou |
Date of birth  出生日期
, 197702112 ,
Home address  家庭住址 No. 461 Green Valley Villas, Jianhe Road, Changning District, Shanghai, Shanghai, 200335, China
No. 461 Green Valley Villas， Jianhe Road， Changning District， 上海， 上海， 200335， 中国		 No. 461 Green Valley Villas, Jianhe Road, Changning District, Shanghai, Shanghai, 200335, China
No. 461 Green Valley Villas， Jianhe Road， Changning District， 上海， 上海， 200335， 中国
Telephone number  电话号码 8613906501195 8618658177227
Parent/Guardien 1 Parent/Guardian 2 Full name "Family name Shen" "Family name Zhou" Date of birth https://cdn.mathpix.com/cropped/2025_06_25_b560791095dec0fd8593g-1.jpg?height=72&width=596&top_left_y=1144&top_left_x=473 , 197702112 , Home address No. 461 Green Valley Villas, Jianhe Road, Changning District, Shanghai, Shanghai, 200335, China No. 461 Green Valley Villas, Jianhe Road, Changning District, Shanghai, Shanghai, 200335, China Telephone number 8613906501195 8618658177227| | Parent/Guardien 1 | Parent/Guardian 2 | | :--- | :--- | :--- | | Full name | Family name <br> Shen | Family name <br> Zhou | | Date of birth | ![](https://cdn.mathpix.com/cropped/2025_06_25_b560791095dec0fd8593g-1.jpg?height=72&width=596&top_left_y=1144&top_left_x=473) | , 197702112 , | | Home address | No. 461 Green Valley Villas, Jianhe Road, Changning District, Shanghai, Shanghai, 200335, China | No. 461 Green Valley Villas, Jianhe Road, Changning District, Shanghai, Shanghai, 200335, China | | Telephone number | 8613906501195 | 8618658177227 |
CUSTODIAN INFORMATION  托管人信息
  姓氏 Boyd
Family name
Boyd
Family name Boyd| Family name | | :--- | | Boyd |

名字 Nicole Katherine
Given name(s)
Nicole Katherine
Given name(s) Nicole Katherine| Given name(s) | | :--- | | Nicole Katherine |

在加拿大的身份 加拿大公民或永久居民
Status in Canada
Canadian citizen or
Permanent resident
Status in Canada Canadian citizen or Permanent resident| Status in Canada | | :--- | | Canadian citizen or | | Permanent resident |
 Date of birth  出生日期

家庭地址 2177 Woodglen Crescent， Burlington ON， L7L 6G9
Home address
2177 Woodglen Crescent
Burlington ON, L7L 6G9
Home address 2177 Woodglen Crescent Burlington ON, L7L 6G9| Home address | | :--- | | 2177 Woodglen Crescent | | Burlington ON, L7L 6G9 |

电话号码 905-845-4681
Telephone no.
905-845-4681
Telephone no. 905-845-4681| Telephone no. | | :--- | | 905-845-4681 |
"Family name Boyd" "Given name(s) Nicole Katherine" "Status in Canada Canadian citizen or Permanent resident" Date of birth "Home address 2177 Woodglen Crescent Burlington ON, L7L 6G9" "Telephone no. 905-845-4681"| Family name <br> Boyd | Given name(s) <br> Nicole Katherine | Status in Canada <br> Canadian citizen or <br> Permanent resident | Date of birth | | :--- | :--- | :--- | :--- | | Home address <br> 2177 Woodglen Crescent <br> Burlington ON, L7L 6G9 | | | Telephone no. <br> 905-845-4681 |
The application of the official seal below confirms that the notary public has received evidence that the custodian is a Canadlan citizen or a permanent resident, is over 19 years of age, and currently resides at the home address stated above.
以下公章的应用确认公证人已收到证据，证明保管人是加拿大公民或永久居民，年满 19 岁，目前居住在上述家庭住址。
I. Nicole Katherine Boyd (name of custodian), hereby solemnly declare that I will undertake the full custodianship for the said student, Zexin Shen (name of student), during their stay in Canada, while under the age of majority in the province in which they reside. As a, qustodian, 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 emergengy.
I. Nicole Katherine Boyd（监护人姓名）特此郑重声明，我将对上述学生 Zexin Shen（学生姓名）在加拿大逗留期间，在其居住省份未满成年年龄期间承担全部监护责任。作为一名 qustodian，我已经做出了必要的安排，以代替父母照顾和支持上述学生。通过签署这份监护人协议，我证明我居住在学生预期住所和学校的合理距离内，并且能够在紧急情况下履行我作为监护人的义务。
Sworn before me at: Burlington (city), in the provinse of Ontario (province/territory). Canada country (if applicable). This qquad\qquad 12 day of qquad\qquad June (month), 2025
在我面前宣誓就职：伯灵顿（城市），安大略省（省/地区）。加拿大国家/地区（如适用）。2025 qquad\qquad qquad\qquad 年 6 月 12 日
qquad\qquad Ontario qquad\qquad Canada (year).
qquad\qquad qquad\qquad 加拿大安大略省（年）。

qquad\qquad 2025 _ (year).
qquad\qquad 2025 _ （年）。

CUSTODIANSHIP DECLARATION PARENTS/GUARDIANS FOR MINORS STUDYING IN CANADA
监护人声明在加拿大学习的未成年人的父母/监护人

STUDENT INFORMATION  学生信息
Family name  姓 Given name(s)  名字 Citizenship  公民权 Date of birth  出生日期 Gender  性
Shen  沈 Zexin  泽欣 China  中国 2011,06,04 ◻ ◻ ◻\square
Name and address of school in Canada
加拿大的学校名称和地址		 ◻ ◻ ◻\square
Appleby College ◻ ◻ ◻\square

学生在加拿大的居住地址 Appleby College 540 Lakeshore Rd W Oakville， ON L6K 3P1
Address where student will reside in Canada
Appleby College
540 Lakeshore Rd W
Oakville, ON L6K 3P1
Address where student will reside in Canada Appleby College 540 Lakeshore Rd W Oakville, ON L6K 3P1| Address where student will reside in Canada | | :--- | | Appleby College | | 540 Lakeshore Rd W | | Oakville, ON L6K 3P1 |
Family name Given name(s) Citizenship Date of birth Gender Shen Zexin China 2011,06,04 ◻ Name and address of school in Canada ◻ Appleby College ◻ "Address where student will reside in Canada Appleby College 540 Lakeshore Rd W Oakville, ON L6K 3P1" | Family name | Given name(s) | Citizenship | Date of birth | Gender | | :--- | :--- | :--- | :--- | :--- | | Shen | Zexin | China | 2011,06,04 | $\square$ | | Name and address of school in Canada | | | | $\square$ | | Appleby College | | | | $\square$ | | Address where student will reside in Canada <br> Appleby College <br> 540 Lakeshore Rd W <br> Oakville, ON L6K 3P1 | | | | |
PARENTS/GUARDIANS INFORMATION (Preferably from both parents/guardians)
父母/监护人信息（最好来自父母/监护人双方）
Parent/Guardian 1  家长/监护人 1 ParenUGuardian 2
Full name  全名 Family name Shen  姓 Shen Given name(s) Yong  名字 Yong Family name Zhou  姓氏：周 Given name(s) Yujun  名字 Yujun
Date of birth  出生日期 1, 197,3,10 22 ∘ ∘ ^(@){ }^{\circ} 1.1977,02 12,
Home address  家庭住址 No. 461 Green Valley Villas, Jiarhe Road, Changning District, Shanghai, Shanghai, 200335, China
No. 461 Green Valley Villas， Jiarhe Road， Changning District， 上海， 上海， 200335， 中国		 No. 461 Green Valley Villas, Jianhe Road, Changning District, Shanghai, Shanghai, 200335, China
No. 461 Green Valley Villas， Jianhe Road， Changning District， 上海， 上海， 200335， 中国
Telephone number  电话号码 8613906501195 8618658177227
Parent/Guardian 1 ParenUGuardian 2 Full name Family name Shen Given name(s) Yong Family name Zhou Given name(s) Yujun Date of birth 1, 197,3,10 22 ^(@) 1.1977,02 12, Home address No. 461 Green Valley Villas, Jiarhe Road, Changning District, Shanghai, Shanghai, 200335, China No. 461 Green Valley Villas, Jianhe Road, Changning District, Shanghai, Shanghai, 200335, China Telephone number 8613906501195 8618658177227 | | Parent/Guardian 1 | | ParenUGuardian 2 | | | :--- | :--- | :--- | :--- | :--- | | Full name | Family name Shen | Given name(s) Yong | Family name Zhou | Given name(s) Yujun | | Date of birth | 1, 197,3,10 22 ${ }^{\circ}$ | | 1.1977,02 12, | | | Home address | No. 461 Green Valley Villas, Jiarhe Road, Changning District, Shanghai, Shanghai, 200335, China | | No. 461 Green Valley Villas, Jianhe Road, Changning District, Shanghai, Shanghai, 200335, China | | | Telephone number | 8613906501195 | | 8618658177227 | |
CUSTODIAN INFORMATION  托管人信息
  姓氏 Boyd
Family name
Boyd
Family name Boyd| Family name | | :--- | | Boyd |

名字 Nicole Katherine
Given name(s)
Nicole Katherine
Given name(s) Nicole Katherine| Given name(s) | | :--- | | Nicole Katherine |
 Status in Canada  在加拿大的地位 Date of birth  出生日期

当前居住地址 2177 Woodglen Crescent， Burlington， ON， L7L 6G9
Current residential address
2177 Woodglen Crescent
Burlington ON, L7L 6G9
Current residential address 2177 Woodglen Crescent Burlington ON, L7L 6G9| Current residential address | | :--- | | 2177 Woodglen Crescent | | Burlington ON, L7L 6G9 |

电话号码 905-845-4681
Telephone no.
905-845-4681
Telephone no. 905-845-4681| Telephone no. | | :--- | | 905-845-4681 |

我/我们的孩子将居住在：与指定的监护人一起住在 scrool 宿舍，或 ◻ ◻◻ \square 替换为另一个人： qquad\qquad （请提供姓名并说明关系）。 INW Yong Shen （辛永勇） qquad\qquad Yujun 周（家长/监护人姓名），所述学生 Zexin Shen（学生姓名）的父母/监护人，特此授予他们居住的 Nicole Katherine Boyd 省份完全监护权。我已经为上述学生的照顾和支持做出了必要的安排，以便监护人可以代替我/我们，即父母。通过签署此监护人协议，我/我们确认我/我们确信上述指定的监护人居住在我/我们孩子的预期住所和学校的合理距离内，并且能够在紧急情况下履行其作为监护人的义务。 监护人签名 （2） （省/地区）、 qquad\qquad 国家/地区（如果适用）。 这一天 qquad\qquad （月）， （年）
My/Our child will reside: with the appointed custodian, in the scrool dormitory, or ◻ ◻ ◻\square with another person: qquad\qquad (please provide name and indicate relationship).
INW Yong Shen qquad\qquad Yujun Zhou
(names of parents/guardians),
the parents/guardians of the said student,
Zexin Shen
(name of student), hereby grant full custodianship to
Nicole Katherine Boyd province in which they reside. 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 safisfied the above appointed custodian resides within a reasonable distance of my/our child's intended residence and school and will be able to fulfil their obligations as a custodian ir the event of an emergency.
Signature of parentiguardian (2)
(province/territory), qquad\qquad country (if applicable).
This day of qquad\qquad (month),
(year)
My/Our child will reside: with the appointed custodian, in the scrool dormitory, or ◻ with another person: qquad (please provide name and indicate relationship). INW Yong Shen qquad Yujun Zhou (names of parents/guardians), the parents/guardians of the said student, Zexin Shen (name of student), hereby grant full custodianship to Nicole Katherine Boyd province in which they reside. 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 safisfied the above appointed custodian resides within a reasonable distance of my/our child's intended residence and school and will be able to fulfil their obligations as a custodian ir the event of an emergency. Signature of parentiguardian (2) (province/territory), qquad country (if applicable). This day of qquad (month), (year)| My/Our child will reside: with the appointed custodian, in the scrool dormitory, or $\square$ with another person: $\qquad$ (please provide name and indicate relationship). | | :--- | | INW Yong Shen $\qquad$ Yujun Zhou | | (names of parents/guardians), | | the parents/guardians of the said student, | | Zexin Shen | | (name of student), hereby grant full custodianship to | | Nicole Katherine Boyd province in which they reside. 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 safisfied the above appointed custodian resides within a reasonable distance of my/our child's intended residence and school and will be able to fulfil their obligations as a custodian ir the event of an emergency. | | Signature of parentiguardian (2) | | (province/territory), $\qquad$ country (if applicable). | | This day of $\qquad$ (month), | | (year) |
Signature of notary  公证人签名 OFFICIAL SEAL OF NOTARY PUBLIC
公证人公章
"Family name Boyd" "Given name(s) Nicole Katherine" Status in Canada Date of birth "Current residential address 2177 Woodglen Crescent Burlington ON, L7L 6G9" "Telephone no. 905-845-4681" "My/Our child will reside: with the appointed custodian, in the scrool dormitory, or ◻ with another person: qquad (please provide name and indicate relationship). INW Yong Shen qquad Yujun Zhou (names of parents/guardians), the parents/guardians of the said student, Zexin Shen (name of student), hereby grant full custodianship to Nicole Katherine Boyd province in which they reside. 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 safisfied the above appointed custodian resides within a reasonable distance of my/our child's intended residence and school and will be able to fulfil their obligations as a custodian ir the event of an emergency. Signature of parentiguardian (2) (province/territory), qquad country (if applicable). This day of qquad (month), (year)" Signature of notary OFFICIAL SEAL OF NOTARY PUBLIC | Family name <br> Boyd | Given name(s) <br> Nicole Katherine | Status in Canada | | Date of birth | | :--- | :--- | :--- | :--- | :--- | | Current residential address <br> 2177 Woodglen Crescent <br> Burlington ON, L7L 6G9 | | | | Telephone no. <br> 905-845-4681 | | My/Our child will reside: with the appointed custodian, in the scrool dormitory, or $\square$ with another person: $\qquad$ (please provide name and indicate relationship). <br> INW Yong Shen $\qquad$ Yujun Zhou <br> (names of parents/guardians), <br> the parents/guardians of the said student, <br> Zexin Shen <br> (name of student), hereby grant full custodianship to <br> Nicole Katherine Boyd province in which they reside. 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 safisfied the above appointed custodian resides within a reasonable distance of my/our child's intended residence and school and will be able to fulfil their obligations as a custodian ir the event of an emergency. <br> Signature of parentiguardian (2) <br> (province/territory), $\qquad$ country (if applicable). <br> This day of $\qquad$ (month), <br> (year) | | | | | | | | | | | | | | | | | | Signature of notary | | OFFICIAL SEAL OF NOTARY PUBLIC | | |