Parent or Guardian Name *

First Name

Last Name

Child 1 Name *

First Name

Last Name

Child 2 Name (Optional)

First Name

Last Name

Child 3 Name (Optional)

First Name

Last Name

Primary Phone Number *

(###)

###

####

Secondary Phone Number (Optional)

(###)

###

####

Does your child or children suffer from any allergies, illnesses, disabilities, or any other medical conditions? *

Yes

No

Walking Program *

Would you like your child(ren) to be picked up at their school? Extra cost (Prices per school, any number of children) 1 Day = $10 3 Days = $15 discounted price

Yes

No

Program Options *

Note that ALL options are 1.5 hours.

Tutoring with homework help

Arts and Crafts ONLY (No tutoring)

Tutoring provided in which language? *

French

English

Which days would you like to sign up your child(ren) for? *

SELECT ALL THAT APPLY Per child: Tutoring with Homework prices: 1 Day/week (1.5 hours) = $40 3 Days/week (4.5 hours) = $110 discount price Arts and Crafts Only prices: 1 Day/week (1.5 hours) = $25 Half price for each additional child = $12.50 3 Days/week (4.5 hours) = $60 discount price

Tuesday

Wednesday

Thursday

How many weeks would you like to sign up for? *

1 Week

4 Weeks

9 Weeks

Other