RCSD Ukrainian Program Registration Form

Regina Catholic Schools Ukrainian Program Registration Form
Student Information
Student Name*

First NameLast Name
Student Birth Date*

DayMonthYear
Grade*
School*
Student Phone Number
Please enter a valid phone number.
Allergies*
Student Home Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Parent Information
Parent/Guardian 1 Name*

First NameLast Name
Parent/Guardian 1 Phone*
Please enter a valid phone number.
Parent/Guardian 1 Email*
example@example.com
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Phone
Please enter a valid phone number.
Parent/Guardian 2 Email
example@example.com
Emergency Contact

Please use someone that is not a parent/guardian listed above.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Session Selection
Preferred Evening*

Wednesday @ 4:30PM-6:30PMThursday @ 6:00PM-8:00PM
Should be Empty:

Student Information