Child Information

Child First Name*

Child Middle Name

Child Last Name*

Child's Address - Street Number and Name*

Child's Address - City*

Child's Address - Province*

Child's Address - Postal Code*

Date of Birth*

Age*

School Grade (in fall)*

Separator

Parent Information

Mother Full Name*

Stepparent?

Mother Email*

Mother Home Phone #

Mother Work Phone #

Mother Cell Phone #

Father Full Name

Stepparent?

Father Email

Father Home Phone #

Father Work Phone #

Father Cell Phone #

Guardian Full Name

Relationship to Child

Guardian Email

Guardian Home Phone #

Guardian Work Phone #

Guardian Cell Phone Number

Mother Employer

Father Employer

Guardian Employer

Status of Parents (i.e. together, separated, divorced, etc)

Emergency Contact Full Name (cannot be parent/guardian)*

Emergency Contact Phone #*

Separator

Pickup Permission

I give permission for the following people to pick up my child from Kids Connection (note: photo id will be required for picking up a child).

Name

Relationship to Child

Phone #

Name

Relationship to Child

Phone #

Name

Relationship to Child

Phone #

Separator

Health Information

Health Card Number*

Name of Doctor*

Doctor's Phone #*

Allergies

Medical Conditions

Physical Conditions

Behavioural/Social Conditions

Is there any other information about the care of your child that we need to know?

Emergency Medical Consent: I hereby give permission for the Supervisor and staff of Kids Connection to act on my
behalf in obtaining and/or authorizing medical treatment if an emergency arises and I cannot be contacted by telephone.
I understand that any treatment would be on the advice of a qualified medical doctor. Children are not to
bring medication to center. Staff do not administer drugs.

Signature*

Date*

Separator

Fee Information and Payment Options

Non-refundable Registration Fee (one fee per family) - $50
Camp Fee (per week, per child) - $175

Payment Method*

Payment via etransfer

If subsidized, what is the parent share?

If fees are being shared by multiple people, please list the names of the payees and what percentage they will pay for each week

Name to Go On End-of-Year Receipt