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After School Care Registration Form
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Child's name
Your answer
Child's date of birth
MM
/
DD
/
YYYY
Child's Nova Scotia Health Card Number
Your answer
Name of Parent(s)
Your answer
Parent Phone Number(s)
Your answer
Parent Email(s)
Your answer
Home Address
Your answer
Family Doctor Name and Number
Your answer
Emergency Contact
Your answer
Please list all adults (name, relationship, phone number) who have permission to pick your child up from Willow Learning House.
Your answer
Does your child have any food allergies or medication requirements?
Your answer
What school does your child attend? Will they be taking the school bus to our program?
Your answer
Please take the space below to share any aspects of your child's personality or history that may be helpful to the teacher.
Your answer
Which days would you like to register your child for? Select all that apply.
Tuesdays 3pm-5pm
Wednesdays 3pm-5pm
Thursdays 3pm-5pm
Fridays 3pm-5pm
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