TEST

Child's Name

Health Card Number

Gender: M or F

MaleFemale

Family Doctor Name

Grade in September

Family Doctor Phone

Date of Birth

Family Doctor Address

Allergies / Puffers / Special Needs / Any Instructions / Comments:

Home Address

Home Phone

Mother

Father

Emergency

Relationship

WEEK

START DATE

END DATE

$170/WK 9AM-4PM

PRE CARE 7AM-9AM

POST CARE 4PM-6PM

CARE HRS *If Applicable

Cost

1

July 6

July 10

1

1

1

1

2

July 13

July 17

1

1

1

1

3

July 20

July 24

1

1

1

1

4

July 27

July 31

1

1

1

1

5

August 3

August 7

1

1

1

1

6

August 10

August 14

1

1

1

1

7

August 17

August 21

1

1

1

1

8

August 24

August 28

1

1

1

1

9

August 31

September 04

1

1

1

1