Empowered Girls STEAM Program Registration Form
Please fill in the form below.
Biweekly on Tuesday's starting January 12, 2020
Child's Name:
*
Age:
*
Date of Birth (MM/DD/YYYY)
*
STEAM Programs:
*
STEAM Program
Tuesday, January 12
Tuesday, January 26
Tuesday, February 9
Tuesday, February 23
Tuesday, March 9
Home Address:
*
Primary Phone Number
*
-
Area Code
Phone Number
School & Grade:
*
Parent/Guardian Name:
*
Parent/Guardian Phone Number
*
-
Area Code
Phone Number
Parent/Guardian E-mail
Emergency Contact Name:
*
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Family Doctor Name:
Family Doctor Phone Number
-
Area Code
Phone Number
OHIP #:
Known Health Issues: (Including Allergies, Medical, or Special Needs)
Photography Release- I give permission for J.A.C. staff to take photographs of my child during programs for potential use in future promotional materials.
*
Yes
No
I have read and understand the information presented in this form. I agree to cooperate with all J.A.C. procedures and regulations. Signature
*
Clear
Would you like to be contacted via text messages about J.A.C.'s programs, workshops, and events?
Yes
No
Submit Form
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