Action jeunesse

Registration
Mohiganech Social Club
For children from kindergarden to Grade 6
Cooking, sciences, arts, sports, traditional activities, outdoor output etc.

36 places maximum

Registration Form

Pedagogical Days
9:00 am to 4:00 pm

Information about the child

* Indique un champ obligatoire

Child's name *

Prénom

Nom

Specify the nation *

Gender *

Boy Girl

Age *

Teacher's name *

Health Insurance Card *

Does the child have allergies? *

If the child have allergies, please specify them *

Does the child have asthma? *

Does the child have diabetes? *

Does the chil has receive his tetanus shot? *

Does the child take medication? *

List of medication *

Water safety *

Does the child have a bike? *

Pedagogical Days in wich the child will participate *

Information about the parents/guardians

Mother's (guardian) name *

Prénom

Nom

Phone (home) *

Phone (work) *

Phone (emergency) *

Address *

Town *

Postal Code *

E-mail *

Father's (guardian) name *

Prénom

Nom

Phone *

Address *

Town *

Postal Code *

E-mail *

Departure of the child

Is the child allowed to leave alone? *

Yes No

Person autorized to pick up the child *

Prénom

Nom

Relation to the child *

Person autorized to pick up the child *

Prénom

Nom

Relation to the child *

Responsabilities

As a parent, I take the responsibility of informing the Social Club facilitators and/or the community organizer, in person, by email, in writing or by telephone, of my child's absence for a day or delay so that facilitators can plan activities and transportation according to the number of children present.

Autorizations

Soumettre