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Early Head Start Registration Form - NDG_Spring 2020
Please fill out all the boxes below to register for the Early Head Start Program
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* Indicates required question
Email
*
Your email
Child's name (first and last)
Your answer
Child's current address: street name, number, and apartment number
*
Your answer
City
*
Your answer
Province
*
Your answer
Postal code
*
Your answer
Telephone number
*
Your answer
Child's age
Your answer
Child's date of birth
*
MM
/
DD
/
YYYY
Child's gender
*
Female
Male
Other:
Preferred language of communication
*
Your answer
Does your child have any allergies or health concerns we should be aware of?
Your answer
Parent/Guardian 1 name (first and last)
*
Your answer
Parent/Guardian 2 name (first and last)
Your answer
Number of classes a week you'd like to attend
1
2
Clear selection
Please check off which days you would like to participate in the program (all classes are from 10am-12pm)
Monday
Wednesday
Both
If there is anyone other than a parent or guardian who will be picking up your child at anytime, please list their name, phone number, and relationship to your child below:
Your answer
In case of emergency please contact: Name (first and last)
*
Your answer
Relationship to child
*
Your answer
Phone number
*
Your answer
Is there anything else you would like us to know about your or your child?
Your answer
Collective Community Services Photo Authorization
*
Yes, I authorize CCS to use any photos of myself and/or my children for use in publicity tools
No, I do not authorize CCS to use any photos of myself and/or my children for use in publicity tools
Option 3
Today's date
*
MM
/
DD
/
YYYY
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