Registration From

My Class Supervision Centre Registration Form
All registrations are received and reviewed on a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Expected Start Date*

MonthDayYear
Date
School Attending*
(Standard or Form)*
Student Information
First Name*
Last Name*
FemaleMale
Birth Date*

MonthDayYear
Home Phone*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

City

Postal / Zip Code
Parent/Guardian Information 1
Full Name*

First NameLast Name
Employer*
Home #
Format: (000) 000-0000.
Cell #*
Format: (000) 000-0000.
Work #*
Format: (000) 000-0000.
E-mail*
example@example.com
YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Parent/Guardian Information 2
Full Name

First NameLast Name
Employer*
Home #
Format: (000) 000-0000.
Cell #
Format: (000) 000-0000.
Work #*
Format: (000) 000-0000.
E-mail
example@example.com
YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Other Infomation
YesNo
YesNo
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?*
Does your child require any medication? If yes, please list these medications.
Yes
Please list the people authorized to pick up your child.
Comments
Emergency Contact - Other than Parent/Guardian
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home #
Format: (000) 000-0000.
Cell #*
Format: (000) 000-0000.
Work #
Format: (000) 000-0000.
Should be Empty:

My Class Supervision Centre Registration Form

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation

Emergency Contact - Other than Parent/Guardian