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SCHOOL YEAR FROM SEPTEMBER, 2003 TO JUNE, 2004
Date: ______________________________
Last Name _____________________________ Gender _____
Child's Name __________________________ Birthdate ___________________ (m/d/y)
Address ____________________________________ City __________________________
Postal Code __________________ Telephone (_____)________________
Mother's Name ______________________________ Occupation
___________________________
Business Address ____________________________ Business Phone (____) __________________
Father's Name _______________________________ Occupation
___________________________
Business Address ____________________________ Business Phone ________________________
Marital Status ___________________
Siblings:
Name ______________________________________ Birthdate ______________________ (m/d/y)
Name ______________________________________ Birthdate ______________________ (m/d/y)
Name ______________________________________ Birthdate ______________________ (m/d/y)
IN CASE OF EMERGENCY
Name ______________________________________ Phone (____) __________________
Name ______________________________________ Phone (____) __________________
Pick-up Authorization:
___________________________________________________________________________________
Allergies or Health Problems of which you wish the school to be aware:
___________________________________________________________________________________
Health Card #:
________________________________
HALF DAY _______ AM_______
PM______ FULL DAY_______
____ Pickering Campus Pickering (415 Toynevale Ave)
____ Rougemount Campus Pickering (365 Kingston Road)
____ Village Campus Ajax (56 Old Kingston Road)
____ Rotherglen Campus Ajax (403 Kingston Road West)
____ Milner Campus, Scarborough (885 Scarborough Golf Club Road)
____ St Mark's Campus Scarborough (115 Orton Park Road)
____ Westney Campus, Ajax (20 O'Brien Court)"
I have read and understand the attached Terms & Conditions.
Signed: ______________________________________________
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Please Read Application Thoroughly.
THIS FORM MUST BE RETURNED TO THE SCHOOL
Fill in all Fields and Attach Application for Blaisdale Administration.
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