Your Email (required)
Child's Name (required):
Child's Date of Birth (required)
Parents Details (Marked * is required):
Name of Person to be contacted in case of emergency (required):
Name of person to whom the child may be released to:
Child's family physician Name*:
Child's family physician Address:
Child's family physician Phone*:
Child's Ontario Health Card# *:
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):
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.