Enrollment form - impact A&C Vancouver

impact Academies & Camps

Enrollment Form

Child details

First and Last Name

Date of birth

Address

City

Province

Postal Code

Parent/Guardian 1 details

First and Last name

Cell #

Home #

Work #

Does this parent have legal access to the child?

Yes

Does the child live with this parent?

Yes

Parent/Guardian 2 details

First and Last name

Cell #

Home #

Work #

Does this parent have legal access to the child?

Yes

Does the child live with this parent?

Yes

Emergency contacts

You must provide at least one emergency contact!

Emergency Contact #1

First and Last name

Relationship

Phone #

Emergency Contact #2 (Optional)

First and Last name

Relationship

Phone #

Child's Medical information

Family Doctor

Family Doctor's Address

Family Doctor's Phone #

Details of any allergies or other medical conditions we should be aware of:

PARENT/GUARDIAN CONSENT AND AGREEMENT FOR EMERGENCIES

As parent/guardian, I consent to have my child, if necessary, to be transported to receive emergency care. I give consent for the emergency contact person listed above to act on my behalf until I am available. I agree to review and update this information whenever a change occurs.

You consent that your child is old enough to come and leave our premisses without supervision

Yes

You consent for your child's photographs and videos to be used as described in Terms&Conditions

Yes

Terms & Conditions

I have read and agree to the Terms & Conditions.