Parent/ Guardian Name *

First Name

Last Name

Parent/ Guardian Phone Number

(###)

###

####

Is this a cell number we can text? *

Yes

No

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child #1 *

First Name

Last Name

Child #1 date of birth *

MM

DD

YYYY

Are there any medical concerns, including allergies, that pertain to your child(ren) that we need to be aware of? *

Yes

No

Are there any learning concerns, including behavioural, that pertain to your child(ren) that we need to be aware of? *

Yes

No

Emergency Contact Designate *

First Name

Last Name

Emergency Contact's Telephone Number *

(###)

###

####

Is this a cell number we can text? *

Yes

No