Children's Information Medical Information
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:
CONTACT INFORMATION
Home Address
Home Phone
Contact Name Cell or Home Email
Mother
Father
Emergency
Relationship
ENROLLMENT FEES INFORMATION
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
Total Number of Weeks
Registration Fee $25/Child: $25.00
Subtotal
HST 13%
Total Fees:
Balance Due: To be added By Owner