Kingpin Cambridge

Child's information

Child's name *

Health card number *

Date of birth *

Gender *

Female Male

Does your child have any medical conditions the staff should be aware of (i.e. allergies)?

Indicate any special medical attention your child may require

For possible future advertising we need consent from parent to include photographs and video of children *

Yes No

Select program date(s): *

April 12, 2019 (full day)

April 22, 2019 (Easter Monday, full day)

May 31, 2019 (full day)

June 28, 2019 (WRDSB only, full day)

Emergency Contact Information

Primary contact

Name *

Home phone *

Work phone

Alternate contact

Name

Home phone

Work phone

P.D. Day Camps