Children’s Information

    Medical Information

    Child’s Name

    Health Card Number

    Gender: M or F

    MaleFemale

    Location

    Grade in September

    Date of Birth

    Allergies / Puffers / Special Needs / Any Instructions (ADD, ADHD, PDD, AUTISM) / Comments:*

    CONTACT INFORMATION

    Home Address

    Home Phone

    Contact Email*

    Contact

    Name

    Cell or Home

    Email

    Mother

    Father

    Emergency

    Relationship

    ENROLLMENT FEES INFORMATION

    WEEK

    START DATE

    END DATE

    $240/WK 9AM-4PM

    PRE CARE 7AM-9AM ($20)

    POST CARE 4PM-5:30PM ($20)

    Cost

    1

    July 03

    July 07

    1

    1

    1

    2

    July 10

    July 14

    1

    1

    1

    3

    July 17

    July 21

    1

    1

    1

    4

    July 24

    July 28

    1

    1

    1

    5

    July 31

    August 04

    1

    1

    1

    6

    August 08

    August 11

    1

    1

    1

    7

    August 14

    August 18

    1

    1

    1

    8

    August 21

    August 25

    1

    1

    1

    9

    August 28

    September 01

    1

    1

    1

    Total Number of Weeks

    Administration Fee $50/Child:

    $50.00

    Subtotal

    HST 13%

    Total Fees:

    Signature*

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