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Registration Form


Employee Information

First Name:
Last Name:
Email Address:
Home Address:
City:
Province:
Postal Code:
Employee #:
Work Location:
Home Tel. #:
Work Tel. #:


Dependent Information

  Name(s): Date of Birth: Sex: Health Card Number
A)
B)
C)


Medical Information

(in order of child as alphabetically identified above: list allergies, chronic medical conditions or special needs)
A)
B)
C)
Doctor's Name: Tel. #:
Language(s) Spoken at home
Pet(s):


Emergency Information

Spouse's/Partner's:

First Name:
Last Name:
Home Tel. #:
Work Tel. #:

Emergency Contact (other than spouse/partner):

First Name:
Last Name:
Home Tel. #:
Work Tel. #:

 

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