Page 1 of 1
Weekend Care Program Registration Form
Child Information
Full Name
(Surname First)
*
Date of Birth
*
Gender
*
Gender
A
Male
B
Female
Home Address
*
Parent/Guardian Information
Priority Contact 1
Title
*
Full Name
*
Phone Number
*
Email Address
*
Occupation
*
Relationship to Child
*
Priority Contact 2
Title
Full Name
Phone Number
Email Address
Occupation
Relationship to Child
Employer Name & Address
Emergency Contact
Full Name
*
Relationship to Child
*
Phone Number
*
Authorized Pick-Up Contacts
Authorized
Contact Name
*
Authorized
Contact Phone Number
*
Note:
Valid ID will be required at pick-up.
Medical Information
Allergies
*
Medical Conditions
*
Immunization Status
*
Admission Requirement
Passport photograph of the pupil
*
Click to choose a file or drag here
Size limit: 10 MB
Birth certificate
*
Click to choose a file or drag here
Size limit: 10 MB
Consent & Agreement
*
Consent & Agreement
I confirm that the information provided in this application is accurate and complete to the best of my knowledge.
I consent to photographs being taken of my child during school activities for documentation purposes.
I understand that photographs may be used in a promotional context and consent to such use.
In the event of an accident, I grant permission for school staff to administer first aid or call an ambulance if necessary.
Signature & Date
Signature
*
Today's Date
*
Submit