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Date: ______________________________
Last Name _________________________________________ Gender __________________
Child's Name _______________________________________ Birth Date ________________ (m/d/y)
Address ______________________________________________________ City __________________
Postal Code _____________ Home Phone (_____) ________________ / (_____) __________________
E-mail Address _______________________________________
Mother's Name _______________________________________ Occupation ____________________
Business Address _____________________________________ Phone (_____) __________________
Father's Name ________________________________________ Occupation ___________________________
Business Address _____________________________________ Business Phone (_____) _________________
Marital Status ________________________
Sibling Name _________________________________________ Birth Date ________________ (m/d/y)
Sibling Name _________________________________________ Birth Date ________________ (m/d/y)
Sibling Name _________________________________________ Birth Date ________________ (m/d/y)
IN CASE OF EMERGENCY
Name ____________________________ Phone (____) ________________ Relationship _________________
Name ____________________________ Phone (____) ________________ Relationship _________________
Pick-up Authorization _________________________________________________________________________
Allergies or Health Problems of which you wish the school to be aware:
____________________________________________________________________________________________
____________________________________________________________________________________________
Health Card # _____________________________
Session Required: HALF DAY AM_______ PM_______ FULL DAY_______
____ Pickering Campus (415 Toynevale Avenue, Pickering)
____ Rougemount Campus (365 Kingston Road, Pickering)
____ Village Campus (56 Old Kingston Road, Ajax)
____ Rotherglen Campus (403 Kingston Road West, Ajax)
____ Milner Campus (231 Milner Avenue, Scarborough)
____ Westney Campus (20 O'Brien Court, Ajax)
____ Whitby Campus (200 Byron Street South, Whitby)
_____Oshawa Campus (1037 Simcoe St. North, Oshawa)
I have read and understand the attached Terms & Conditions.
Signed: ______________________________________________ (Parent’s/Guardian’s Signature)
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