StrongStart Registration | Innovative Learning

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Parent/Guardian Info

Parent/Guardian

Parent/Guardian
First Name Last Name Parent/Guardian Type Mother Father Other… Enter other… Phone Email Street Address City Province Postal Code

Emergency Contact

Emergency Contact
First Name Last Name Relationship to Child Home Phone Work Phone Cell Phone Can this contact pick up the Child? Yes No

Health Conditions

Life Threatening Condition

Yes

Yes, Anaphylactic

Yes, Asthma that has resulted in hospitalization in the past year

Yes, Blood Clotting Disorder

Yes, Diabetes

Yes, Epilepsy with a history of Tonic-Clonic (Grand Mal) seizures in the past two years

Yes, Serious Heart Condition (e.g. heart murmur, heart repair)

Yes, Other Health Conditions which may require emergency care - please specify

Non-Life Threatening Condition

Non Life Threatening Health Condition (food allergies/sensitivities): Please describe

Declaration: By submitting this information for StrongStart registration, I also certify that the information I have provided on this form is correct.