March break camp registration form

Georgetown Taekwondo

March Break Camp

Registration Form

Student Information

Student First Name : *

Student Last Name: *

Date of Birth: *

Student’s School Name:

Start Date of Student’s School March Break in 2012: *

End Date of Student’s School March Break in 2012: *

Is the student currently attending our Before/After School Transported Program?: *

Yes

Parent/Guardian Information

Parent First Name: *

Parent Last Name: *

Address:

City: *

Province: *

Postal Code: *

Email Address: *

Home Phone:

Cell Phone:

Work Phone:

Spouse/Other Parent First Name: *

Spouse/Other Parent Last Name: *

Spouse/Other Parent Home Phone (if different from above):

Spouse/Other Parent Cell Phone:

Spouse/Other Parent Work Phone:

Other Emergency Contact First Name: *

Other Emergency Contact Last Name: *

Other Emergency Contact Home Phone: *

Other Emergency Contact Cell Phone:

Other Emergency Contact Work Phone:

I am also interested in information about Georgetown Taekwondo’s Transported Before and After School Program: *

Yes

I prefer to be contacted by: *

Home Phone

Cell Phone

Work Phone

905-873-2809
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