Email address
*
Child's Legal Surname
*
Other Surnames (if any)
Legal First Name
*
Preferred Name
Date of Birth
*
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Gender
*
Male
Female
Other
Ontario Health Card Number
*
Preferred Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal Code
Alternate Mailing
Street Address
Street Address Line 2
City
State / Province
Postal Code
Legal Parent / Guardian 1
Name
*
Preferred Phone
*
Phone Type
*
Home
Cell
Work
Alternate Phone Number
Phone Type
Home
Cell
Work
Legal Parent / Guardian 2
Name
Preferred Phone
Phone Type
Home
Cell
Work
Alternate Phone Number
Phone Type
Home
Cell
Work
Current Preschool / Childcare
*
Previous Preschool / Childcare
*
Please attach your child's most up to date immunization history or exemption letter
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