Program Registration
Esterhazy Public Library
Child Information
Please fill out a separate form for each child.
Child’s Name
*
First Name
Last Name
Birth Date
*
Parent/Caregiver Information
Parent/Caregiver Name
*
First Name
Last Name
Municipality of Residence (For Library Statistics)
*
Street Address
Street Address Line 2
(Town of Esterhazy, RM of Fertile Belt, etc.)
State / Province
Postal Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
Program Selection
Select the program(s) you would like to register for.
*
1000 Books Before Kindergarten (Ages 0-5)
Idea Hour (Wednesdays at 3:45pm, Ages 7-12)
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1000 Books Before Kindergarten
When will your child be starting Kindergarten? (approx.)
*
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Month
-
Day
Year
Date Picker Icon
I understand that all physical and print materials provided for this program must be picked up at Esterhazy Public Library.
*
I understand.
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Idea Hour
Wednesdays at 3:45pm - Ages 7-12
Does your child have any allergies or other health conditions that library staff should be aware of?
*
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Agreement
Esterhazy Public Library may photograph my child/use photographs of my child that I have shared with them for reporting, advertisement, social media, and other relevant purposes.
*
I agree.
I do not agree.
Electronic Signature
*
By typing your full name in this field, you confirm that all above information is correct and give permission for your child to participate in program activities at Esterhazy Public Library.
Today’s Date
*
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