PRO-D DAY REGISTRATION
2014/2015 SCHOOL YEAR
o September 19, 2014 o October 24, 2014 o November 28, 2014 o January 30, 2015 o March 2, 2015 o May 8, 2015 Child Information: Last Name:
First Name:
Middle Name/Initial:
Birthdate (M/D/YYYY): Street Address:
City, Province:
Age: Postal Code:
BC Care Card Number:
Allergies or Medical Conditions we need to be aware of:
In the case of an emergency, I give permission for NEAT to call upon the local hospital or ambulance to treat my child, _______________________________. Name:___________________________________ Parent/Guardian #1 Information: Name: Relationship to Child: Email: Home Address (If different from above ):
Home Phone:
Cell Phone:
Employer:
Work Phone:
Best way to reach you: Cell o Work o Home o
Parent/Guardian #2 Information: Name: Relationship to Child:
Email:
Home Address (If different from above ):
Home Phone:
Cell Phone:
Employer:
Work Phone:
Best way to reach you: Cell o Work o Home o
General Information/Waiver: Emergency Contacts (other than parents/guardians):
Contact Number:
Persons Authorized to Pick Child/ren Up: Yes o
Are promotional photos ok?
No o
I give permission for my child, __________________________________, to leave the facility under the supervision of NEAT employees to participate in Pro-D Day activities. Yes o No o
Parent Signature: __________________________________________ Date:____________________________
$40/day or $210/6 days. 2nd child receives 10% off daily cost OFFICE USE ONLY: PAID:
DATE: _________________________ AMOUNT:_$__________________ CASH o
CHEQUE (#__________) o
DEBIT/CREDIT o