Enrolment Form

Child 1 First Name*

Child 1 Last Name*

Child 1 Birth Date*

Program: *

Child 2 First Name

Child 2 Last Name

Child 2 Birth Date

Program:

Address*

City*

Postal Code*

Parent 1 First Name*

Parent 1 Last Name*

Parent 1 Phone*

Parent 1 Email*

Parent 1 Occupation*

Parent 1 Bus. Phone*

Parent 1 Bus. Address*

Parent 1 Home address if different from above:

Parent 2 First Name

Parent 2 Last Name

Parent 2 Phone

Parent 2 Email

Parent 2 Occupation

Parent 2 Bus. Phone

Parent 2 Bus. Address

Parent 2 Home address if different from the child:

Deposit amount* $

Registration amount* $

Date paid*

Payment method*

Cheque #

York Region subsidy * YesNoIn process

If Yes, Parent daily contribution amount $

Emergency Contact (other than parents)*

Phone*

Emergency Contact Address*

Name(s) of adults authorized to pick up your child

Preferred start date*

Date of discharge*

Family physician's name*

Phone Number*

Address*

Child’s previous medical history requiring medical attention, immunizations*

Instructions concerning any special requirements in respect of diet, rest, exercise*

Parent/Guardian name, print please*

Submission date*