Bountiful Blessings After School Program

Bountiful Blessings After School Program Registration

Every other Thursday afternoon from 3:00 pm to 6 pm Location: 30Ave. Queen, Pointe-Claire, QC, H9R 4G2
All registrations are received and reviewed

on a first come, first serve basis.
School/Transport Information
Name of School
Current Grade
Which subjects do you require assistance with?
Student Information
First Name*
Last Name*
Gender*

FemaleMale
Birth Date*

MonthDayYear
Home Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Health Care # (in case of emergency)*
Parent/Guardian Information 1 (For Minors Only)
Full Name

First NameLast Name
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail
Address - Same As Child

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 / Province

Postal / Zip CodeCountry
Parent/Guardian Information 2
Full Name

First NameLast Name
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail
Address - Same As Childs

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
Do you/the child have any allergies?*

YesNo
If yes please list, including any food or drug allergies.
Do you/the child have any medical conditions?
Does you/the child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed above?

YesNo
Please list the people authorized to pick up your child.
Comments
Does your child have a learning disability or neurodivergent ?*
If so, please specify the issue
Do you consent to you / your child being photographed and/or filmed?*
Emergency Contact

For minors - the emergency contact should be someone other than the parent(s) listed.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to the waiting list.
Should be Empty:

Bountiful Blessings After School Program Registration

School/Transport Information

Student Information

Parent/Guardian Information 1 (For Minors Only)

Parent/Guardian Information 2

Other Infomation

Emergency Contact