Program Registration Form

Program Registration Form

1650 Elgin Mills Road East (Elgin Mills Campus)
Student(s) Information
First Child*

First NameLast Name
Second Child

First NameLast Name
First Child's Birthday*

MonthDayYear
Date
Second Child's Birthday

MonthDayYear
Date
Current School*
Grade in Sept 2024 (First child)*
Grade in Sept 2024 (Second child)
Allergies*
input n/a for none
Special Medical, Physical or Emotional Needs that our teachers should be made aware of.
Parent Information
Parent Name*

PrefixFirst NameLast Name
Cell Number*
Work Number
E-mail*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consent*

I agree to receive e-mails from JEI Learning Center containing information regarding JEI Learning Center’s promotions. I can withdraw my consent at any time. (Please refer to our Privacy Policy or contact us for more details.)
Emergency Contact Information (Other than parent) - if applicable
Emergency Contact Name

First NameLast Name
Phone Number
Relationship
Authorized for pick-up

YesNo
Program(s) of interest - please choose the specific program for which you wish to receive information.
JEI Subject Programs

JEI English (JK-Grade 3)JEI Reading & Writing (Grade 3-8)JEI Math (JK-Grade 8)Subject Evaluation
After School Club (JK-Grade 6)

5 days program4 days programShuttle School Pick-up required
PA Day Camp 9am-3pm, Pizza included | Extended hours 3-5pm $15/day

Friday, January 17, 2025 - $95.00Friday, January 31, 2025 - $95.00Monday, June 9, 2025 - $95.00Friday, June 27, 2025 - $95.00
Winter Camp (4 days) Aussie Winter Escape (JK-Grade 4)

Dec 30-31 and Jan 2-3, 9am-3pm $375.00Dec 30-31 and Jan 2-3, 9am-5pm $435.00Add-on 8am drop-off $45.00Daily Rate 9am-5pm $95.00
March Break Camp All Things Disney (JK-Grade 4)

March 10-14, 2025, 9am-3pm $445.00Includes One JEI Enrichment 9am-5pm $525.00Includes One JEI Enrichment 8am-5pm $575.00Add-on 8am drop-off $50.00Add-on Lunch Plan $75/week (5 days)
Summer Camp (JK-Grade 4)

Summer Camp July 7-11 Wild Nature WondersSummer Camp July 14-18 Hogwarts QuestSummer Camp July 21-25 Gotta Catch'em AllSummer Camp August 11-15 Level Up: Classic Video GamesSummer Camp August 18-22 Pixar Imagination StationSummer Camp Add-on 8am-9am $40/weekSummer Camp Add-on 3-4pm $75/week (One JEI Program)Summer Camp Add-on 3-5pm $145/week (Two JEI Programs)Summer Camp Lunch Plan $55/week (4 days)
Leaders in Training Summer Camp (Grade 5-8)

Summer Camp Week#5 Aug 19-23 Anatomy DiscoverySummer Camp Add-on 8am-9am $40/weekSummer Camp Add-on 3-4pm $85/week (One JEI Program)Summer Camp Add-on 3-5pm $165/week (Two JEI Programs)Summer Camp Lunch Plan $85/week (4 days)
Comments
Terms & Conditions
Please click yes if you WILL give permission to have photographs taken of your child*

YesNo
We occasionally take pictures of the kids in action with the materials or doing other activities for our website, and various Social Media platforms. We hope to use these to keep parents up to date on the happenings at the center.
How did you find us?*
If you were referred by a friend please let us know who, so we can thank them!
Parent Signature*

Clear
Enter the message as it's shown*
IMPORTANT: This form simply accepts your registration information. It is not a confirmation of guaranteed enrollment, as spaces in our class and camp programs are limited. We will contact you within two business days to communicate if your desired session is available. If it is, we will formally confirm your registration and send you the program information packet and payment link. Thank you for your attention.
Time

Hour Minutes

AM/PM Option
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