Winter Break Richmond Application Form

REGISTRATION INFORMATION
RICHMOND WINTER VACATION 2018 OUTSIDE PARTICIPANT APPLICATION FORM - Please complete all required information – incomplete registrations will not be processed
PLEASE ATTACH A RECENT PHOTO OF YOUR CHILD

All Fields are required to be completed

Participant Information

Child's Sex
MaleFemale

Siblings Attending
BrotherSisterSeveralNone

Who has custody?
MotherFatherBothOther


Medical History and Information

Medical and Health Information Continued

Does your child require medication to be administered during the program?
YesNo

Please note: “Request to Administer Medication” form MUST be completed prior to any medication being administered by a staff person.

MildModerateSevere/Life-threateningN/A

YesNo

VegetarianLactose IntolerantSpecific Food AllergyOther

Registrations without these attachments will not be processed.


PARENT AGREEMENT FORM

PLEASE ATTACH A RECENT PHOTO OF YOUR CHILD


(a) I give permission for my child's photograph to be taken during the winter program for use within the centre.
YesNo

(b) I give permission for the image/photo of my child to be used to promote Tomorrow's Topkids in brochures, photo displays, posters, website or social media
YesNo



Registrations without payment will NOT be accepted.
Please return by 6:00pm on Friday December 1st

Select Program
FERRISWESTWIND

$50.00/day or
$208.00 for all days

My child will be attending the following days (please mark days with X)
December 27thNo

My child will be attending the following days (please mark days with X)
December 28thNo

My child will be attending the following days (please mark days with X)
January 2rdNo

My child will be attending the following days (please mark days with X)
January 3thNo

My child will be attending the following days (please mark days with X)
January 4thNo

Winter Break Richmond Credit Card Form
Visa and MasterCard Payments

Credit Card Information:
VisaMastercard




Registrations without payment will not be accepted.