Contact Information Form Winnipeg School Division

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CONTACT INFORMATION
Child’s name:___________________________________________________________________________________________________________
Please indicate which programs your child(ren) will be attending (circle all that apply)
Lunch Program
Before-School
After-School
Primary Contact Name:
Secondary Contact Name:
Address: _____________________________________________
Address: ___________________________________________________
Home Phone Number: __________________________________
Home Phone Number: ________________________________________
Work Phone Number: __________________________________
Work Phone Number: ________________________________________
Cell Phone Number: __________________________________
Cell Phone Number: ________________________________________
Email: _______________________________________________
Email: _____________________________________________________
Alternate Care (Name and Relation): ______________________________________________________
Home Phone Number: _____________________ Address: ____________________________________
Work Phone Number: _____________________
Cell Phone Number: ___________________________
I acknowledge that my child(ren) fully understand the rules and behaviour expectations as detailed in the Handbook (available in the General Office
and at ) and that my child(ren) will abide by those rules.
Parent/Guardian Signature: _______________________________________ Date: ________________
Volunteer workers at the Lunch Program must complete a Child Abuse Registry Form.
Does your child have a Health Care Plan (HCP) at École Riverview School? (please circle)
YES
NO
I ____________________________ give permission for École Riverview School to share _______________________’s HCP with the Before Lunch
After School Programs (BLAS).
I also give permission for my child’s photo to be displayed as one of the children with a HCP. (please circle)
YES
NO
Parent/Guardian Authorization _________________________________________
Questions or concerns regarding the BLAS programs may directed to
or by calling 204-284-5444
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