Registration Form Child's First Name * Child's Last Name * Address * City * Postal Code * Phone Number * Birthdate mm/dd/yyyy * Ontario Health Card Number * Child's Doctor * Primary Parent/Guardian (lives with child) Primary Parent/Guardian Name * Email Address * Primary Phone * Secondary Phone Please check N/A if Employer section does not apply to you N/A Employer * Employer Phone * Employer Address * Secondary Parent/Guardian Secondary Parent/Guardian Name * Secondary Parent/Guardian Address * Same as child Different than child Please enter full address * Primary Phone for Secondary Parent * Secondary Phone for Secondary Parent Secondary Parent Email Address Please check N/A if Employer section does not apply to the secondary parent N/A Secondary Parent Employer * Employer Phone Number * Employer Address * Emergency Contact Information (Must be someone other than parent or guardian) Emergency Contact Name / Relationship / Phone Number * Emergency Contact Full Address * Primary Phone Number * Secondary Phone Number Please check N/A if Employer section does not apply to Emergency Contact N/A Emergency Contact Employer * Employer Phone Number * Employer Address * Pick Your Program Program * Toddler Class (1.5-2.4) Pre-school Class (2.5-5) Days per week * 2 Day 3 Day 5 Day Would you be interested in an afternoon class if offered? Yes I am interested in an afternoon class No I am not interested in a afternoon class Start Date (must be at least 18 months as of start date) Payment Information Electronic Payments are processed on the 1st of every month The information you provide here is only for your monthly payments, you will be asked again at the end to enter payment information for registration, you may use a separate form of payment if you wish. Payment Type * Visa MasterCard Post Dated Cheques Credit Card Number Expiry CVV (3 digits on back) Name on Card St David's Charges a $30 registration fee that is due upon registration. We also charge a $100 Family Contribution Fee which can be paid at your convenience. If you have chosen to pay by post dated cheque, they are due at the General Meeting in August. You will be notified by email the date of the meeting. You will be directed to our shopping app to pay the registration fee after clicking submit. Your place is not held until we receive your $30 payment. Please choose below when you will pay the $100 Family Contribution Fee Payment of Family Contribution Fee * Credit Card Debit Post Dated Cheque Website When I will add it to my payment today when I checkout Please process my card on the date indicated in Comments I will pay at the school I wish to make installments Additional Comments I certify to the best of my knowledge the above information is true and am aware that any changes to the above information must be reported to St. David’s Co-op Nursery School immediately in writing to the Registrar. By clicking the Submit button below I realize that it is as if I signed the form in ink.