2018 REGISTRATION FORM

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Kid’s Club 2017/2018 REGISTRATION FORM

Cost Early bird rate $35 per child/Session after start of session $40 per child/session Online registration and credit card payment available at: www.willowparkchurch.com REGISTRATION INFORMATION Applicant’s Name________________________________ Session 1 : Sept.12-Nov. 28,2017

Y/N

Paid____

Session 2: Jan. 9 -Mar.13,2018

Y/N

Paid____

Grade Entering Sept/17______ Parents/Guardian’s Name;_______________________

MEDICAL INFORMATION Applicant’s Name: ____________________________ Date of Birth: __________________________________ Care Card #: ___________________________________ Allergies/Medications/Limitations __________________________________________________

Address: ________________________________________ Emergency Contact: ___________________________ City: ________ Province: _____Postal Code: ________ Phone #: ___________________Cell#_________________ Email: ____________________________________________