Child Info Legal First Name * Legal Last Name * Legal Middle Name(s) Usual First Name * Usual Last Name * Usual Middle Name(s) Birthday * Year19971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 Year MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Gender at Birth * Female Male Gender Identity * Female Male Non-binary Proof of age * Original Birth Certificate Passport Landed Immigrant Authorization INAC Status Card Custody (Select One) * Both Parents Mother Father Other, specify Child Custody Other * Court Order (select one) * No Yes, describe Court Order: Describe * Home Address * City * Province * Postal Code * Languages spoken at home * Which program will you attend most often? * - Select -Brent Kennedy ElementaryBlewett ElementaryCanyon Lister ElementaryCrawford Bay SchoolCreston Ed CenterHume ElementaryJewett ElementaryJVHumphries SchoolRedfish ElementaryRosemont ElementaryW.E.Graham SchoolWinlaw Elementary Will you attend any other programs? Choose all that apply * Brent Kennedy Elementary Blewett Elementary Canyon Lister Elementary Crawford Bay School Creston Ed Center Hume Elementary Jewett Elementary JVHumphries School Redfish Elementary Rosemont Elementary W.E.Graham School Winlaw Elementary Parent/Guardian Info First Name * Last Name * Parent/Guardian Type * Mother Father Other, please specify Parent/Guardian Type Other * Parent/Guardian Phone * Parent/Guardian Email * Parent/Guardian Address * Parent/Guardian Address City * Parent/Guardian Address Prov * Parent/Guardian Address Postal * Add another Parent/Guardian Emergency Contact Info Emergency Contact #1 First Name * Last Name * Relationship to Child * Homephone * Workphone Cellphone Can this contact pick up the Child? * Yes No Add another emergency contact Life Threatening Condition Yes No Life Threatening Condition * Yes, Anaphylactic Anaphylactic? Anaphylactic - Description Yes, Asthma that has resulted in hospitalization in the past year Asthma that has resulted in hospitalization in the past year? Asthma that has resulted in hospitalization in the past year - Description Yes, Blood Clotting Disorder Blood Clotting Disorder (e.g. haemophilia)? Blood Clotting Disorder (e.g. haemophilia): Describe Yes, Diabetes Diabetes? Diabetes: Describe Yes, Epilepsy with a history of Tonic-Clonic (Grand Mal) seizures in the past two years Epilepsy with a history of Tonic-Clonic (Grand Mal) seizures in the past two years? Epilepsy with a history of Tonic-Clonic (Grand Mal) seizures in the past two years: Describe Yes, Serious Heart Condition (e.g. heart murmur, heart repair) Serious Heart Condition (e.g. heart murmur, heart repair)? Serious Heart Condition (e.g. heart murmur, heart repair): Describe Yes, Other Health Conditions which may require emergency care - please specify Other Health Conditions which may require emergency care - please specify? Other Health Conditions which may require emergency care - please specify: Describe Non-Life Threatening Condition Non Life Threatening Health Condition (food allergies/sensitivities): Please describe Proof of Age * Upload i.e. Birth Certificate, Permanent Residence Card, Aboriginal Status Card More informationFiles must be less than 15 MB. Allowed file types: gif jpg jpeg png pdf doc docx. Declaration * By submitting this information for StrongStart registration, I also certify that the information I have provided on this form is correct. Leave this field blank CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
