Intellidance at Ermineskin Community Centre - Registration Form - April 17 to May 29, 2020
Fridays from 10:15-11 am
*Registration and payment are due at first class or to the ECL office prior.
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Children's Information
Child 1's Name
*
First Name
Last Name
Child 1's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Health Concerns, Allergies
*
Child 2's Name
First Name
Last Name
Child 2's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Health Concerns, Allergies
Emergency Information
Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship
*
Payment
ECL Members $70 , Non-members $84 (if using PayPal additional administrative fee of $3.50 is charged)
Ermineskin Community League Membership Number
Select your form of payment
Cash (bring to first class)
Cheque made out to Ermineskin Community League (bring to first class)
Paypal
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Class Registration Fee, ECL Members
$73.50 CAD
$
73.50
CAD
Class Registration Fee, Non-Members
$87.50 CAD
$
87.50
CAD
Total
$0.00 CAD
$
0.00
CAD
Submit
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