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IMM 5646 (08-2018) E
PROTECTED WHEN COMPLETED - B
(AUSSI DISPONIBLE EN FRANÇAIS - IMM 5646 F)
ALSO AVAILABLE ON CIC WEB SITE AT : http://www.cic.gc.ca
CUSTODIANSHIP DECLARATION -
CUSTODIAN FOR MINORS STUDYING IN CANADA
STUDENT INFORMATION
Family name Given name(s) Citizenship
Y D M
Date of birth Sex
FemaleMale
Name and address of school in Canada
Address where student will reside in Canada - Please select one
PARENTS/GUARDIANS INFORMATION (Preferably from both parents/guardians)
Parent/Guardian 1 Parent/Guardian 2
Full name
Family name Given name(s)Family nameGiven name(s)
Date of birth
Y D M Y D M
Home address
Telephone number
CUSTODIAN INFORMATION
Family name Given name(s)
Status in Canada
Permanent resident
Canadian citizen or
Y D M
Date of birth
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.
Sworn before me at: (city), in the province of (province) country or territory
(if applicable)
This day of (month) (year).
OFFICIAL SEAL OF NOTARY PUBLIC
Signature of custodian
Year Day Month
Date
Signature of notary
Quest Language Studies
#200-432 Church Street, Toronto, ON, M5B2A4
Custodian Address, Toronto, Ontario, Canada
Designated Learning Institution # O19375993682
