Your Email (required)
Child's Name (required): First Name*: Last Name*:
Child's Date of Birth (required) Year*: Month*: Day*: Home Address*:
Parents Details (Marked * is required): Name*: Relationship*: Home Address*: Cell/Page#*: Home Phone#: Work Address: Work Phone#: Extension#:
Name of Person to be contacted in case of emergency (required): Name*: Phone*:
Name*: Phone*:
Name of person to whom the child may be released to: Name*: Phone*:
Child's family physician Name*: Child's family physician Address: Child's family physician Phone*:
Child's Ontario Health Card# *: Child's Allergies*:
Child's previous history of communicable diseases (e.g. Chicken Pox etc.)*
Symptoms of Child's ill health (indicate child's usual reaction to illness e.g. high temperature, flushing, vomiting, irritability etc.)*
Special requirements (if any): Other Information:
I shall provide the school with a copy of my child's immunization record.
I agree the information given is to the best of my knowledge and will be verified again before final admission of the child.