February 6, 2012 #2-410 Duchess Street
S7K 0R1
Office: 933-3547
Cell: 229-1776
 
SUMMER CAMP Registration
(for spring classes go here)
Family Information
Students' Last Name:
Address:
City/Town:
Postal Code:
Phone:
Email:
 
Mothers' Name:
Fathers' Name:
 
Emergency Contact Information
Primary Contact
   Name:
   Phone:
 
Physician
   Name:
   Phone:
   Hospital of Choice:
 
Child/Program Info
 1  Name: Born: Health Card#:
 
Program:

 2  Name: Born: Health Card#:
 
Program:

 3  Name: Born: Health Card#:
 
Program:

Additional
Comments: