Registration
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Holiday Program NON MEMBERS - Thursday 15th April 2021 - 4-12 yrs of age 10.30am-1.00pm - Learn - Play - Engage ** please bring along a fruit snack for when you attend the Holiday Program
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Mother/Father/Career
Carer
Department
Father
Grandparent
Guardian
Mother
Nanny / Au Pair
Other / Accounts
Parent
Self
Step Parent
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State/Prov:
*
Postal Code:
*
Emergency Contact Info (Not Contact #1 or #2)
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=dd/mm/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Photo permission (Y/N)?:
*
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=dd/mm/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Photo permission (Y/N)?:
*
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=dd/mm/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Photo permission (Y/N)?:
*
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=dd/mm/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Photo permission (Y/N)?:
*
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=dd/mm/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Photo permission (Y/N)?:
*
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number:
*
Visa
Mastercard
Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
01
02
03
04
05
06
07
08
09
10
11
12
Exp Year:
*
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
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2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
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2053
2054
Address Line 1:
Address Line 2:
City:
State/Prov:
Postal Code:
*
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