Register

Student Name*

First Last

Name of Elementary School*

Grade

Teachers Name

Parent Name #1*

First Last

Parent #1 Cell Phone*

Parent #1 Home/Work Phone

Parent #1 Email*

Parent Name #2 (optional)

First Last

Parent #2 Phone (optional)

Parent #2 Email (optional)

Program Desired*

Billing Address*

Street Address Address Line 2 City Province Postal Code

PICK UP INFORMATION (fill out for after-school programs only)

Name Of Pick up Person One Name Of Pick up Person Two Or I give my child permission to walk home

Total

$ 0.00 CAD

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Post Custom Field