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16 February 2024

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Little Scientist Fun Club

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Early Years Services – Registration Form:
Parent's Information
Personal Information
*First Name
*Last Name
*Age
*Gender
* Date of Birth (YYYY-MM-DD):
Please fill in at least one of the two phone number input boxes
*Phone:
*Mobile:
*Email
*Address
*Postal Code
*City
*Province
*Years in Canada:
Immigration Status and Information
Immigration Status
Country of Origin:
*Home Language:
Child's Information
*First Name
*Last Name
*Gender
Date of Birth:
Status in Canada
Status Other
* Home Language:
 
Emergency Information
*Health Card #
*Family Doctor's Name
*Family Doctor’s phone #
*Parent's/Guardian’s Name
*Parent/Guardian’s phone #
For any reason, if parents/ guardian cannot be reached during an emergency, please provide two emergency contact number:
Emergency Contact Name #1
*Name
*Relationship
*Telephone
Emergency Contact Name #2
*Name
*Relationship
*Telephone
*Does your child suffer from any health conditions? Please specify.
*Is your child currently on any medication, please specify:
*Food Allergies
*Medication Allergies
*Other Allergies
Additional Comments
Parent/Guardians Authorization
Agreement , Consent & Medication Authorization * Participants should take care of their own safety. CICS is not liable for any personal injury and/or loss/damage of personal property.
I hereby give CICS the right to obtain media recording including but not limited to photographs and videos of myself for promotional and any other uses by CICS through its media outlets.
I hereby give permission to CICS to deliver agency information to my email address.
* I hereby give permission for my child to participate in the above activity and to receive emergency treatment, if necessary. I hereby release CICS from all claims arising from any accident, loss or injury which are caused by or arisen from such participation and/or treatment.
* Security Number: Type the numbers you see in the block
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