Fillable Please Complete One Registration Form Per Child printable pdf download

Please Complete One Registration Form Per Child

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Please complete one registration form per child.

(This is a fillable PDF form. Simply tab or select and type in the information required. It can be printed, saved and/or emailed)

Female

Male

Child’s First Name

Gender

Middle Initial

Last Name

Age

Birthday: Month

Day

Year

School Name

Grade

Yes

Does your child have special needs and require ‘One-to-One’ care?

(If uncertain please call us @ 905 528-0011, Ext 3602)

Please identify your child’s disability:

Home Address:

No.

Street Name

Apt. #

City

Postal Code

Home Phone:

E-mail Address:

Name of Mother/Guardian:

Name of Father/Guardian:

Mother’s Phone:

Father’s Phone:

Mother’s Cell/Bus:

Ext.:

Father’s Cell/Bus:

Ext.:

Select your P.A. Days:

Our P.A. Day programs will be held at Marydale Park, located at 5999 Chippewa Rd. in Mount Hope from 7:30am-4:30pm

daily. Please select the days you are interested in having your child attend:

January 16, 2015 (French)

June 5, 2015 (Catholic, French & Public)

January 23, 2015 (Catholic & Public)

June 19, 2015 (Catholic & French)

April 24, 2015 (Catholic)

Method of Payment:

Please remember that P.A. Day program costs $30.00 per day.

Cancellation Policy: A $15.00 cancellation fee will be charged if a session is cancelled.

I will be sending you a Cheque or Money Order for $___________________ Mail to: C.Y.O. Chippewa Rd, Mount Hope, ON L0R 1W0

None

Please charge $_______________to my Credit Card:

Credit Card #:

Expiry Date:

Yes

Cardholder Name:

Would you like us to send you a receipt via email:

Mail

On receipt of this registration and deposit a Confirmation Package will be sent to you. Please send it to me by:

Questions about registration or camp? Call: (905)528-0011 ext. 3602 Email:

cyooffice@cyo.on.ca

C.Y.O. Office Use Only:

Date Received:__________________ Confirmation Sent: Yes □ No □ Date Sent: _______________

Please Complete One Registration Form Per Child

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