FullRegistration2016

Student Information

ACE Registration

A deposit of $90 will be required at the end of your registration to hold your spot for September.

Child's Registration Number (PIN)

Email To Receive Confirmation

Child's Last Name

Child's First Name

Gender

Male Female

Date of Birth

yyyy/mm/dd

School

Grade in Sept. 2016

Street Address

City

Postal Code

Medical Information (Life Threatening illnesses must be discussed with the Program Co-Ordinator in order to ensure the safety of All participants in the program).

Child's Physician

Physician Phone Number (111 222 3333)

Allergies, Select one

Yes No

If yes please explain

Epipen

Yes No

Other Medical Information - please specify

Parent Information

Tax Receipt to go to

Mother Father Split

Mother's Last Name

Mother's First Name

Mother's Home Phone (111 222 3333)

Mother's Cell Phone (111 222 3333)

Mother's Work Phone (111 222 3333)

Father's Last Name

Father's First Name

Father's Home Phone (111 222 3333)

Father's Cell Phone (111 222 3333)

Father's Work Phone (111 222 3333)

Emergency Contact Name

Emergency Relationship

Emergency Home Phone (111 222 3333)

Emergency Cell Phone (111 222 3333)

Emergency Work Phone (111 222 3333)

Release Information. Please include your name and anyone (including the emergency contact person) to whom your child may be released.

1, Release Name

Relationship

2. Release Name

Relationship

3. Release Name

Relationship

4. Release Name

Relationship

I give ACE permission to collect my child's personal information for registration purposes

Yes No

I give ACE permission for my child or my child's work to be photographed or videotaped by ACE.

Yes No

I give ACE permission to include my child or my child's work in publications produced by ACE.

Yes No

Short Term and AM Programs

If you need PM care for your child(children) in the weeks before the formal ACE programming begins (Sept 19th) Short Term Programming is available for $11.25/hr to a maximum of $90/week. Please check all dates that apply.

Short Term Fees are Non-Refundable

Tuesday Short Term

Sept 6th Period 1 Sept 6th Period 2 Sept 13th Period 1 Sept 13th Period 2

Wednesday Short Term

Sept 7th Period 1 Sept 7th Period 2 Sept 14th Period 1 Sept 14th Period 2

Thursday Short Term

Sept 8th Period 1 Sept 8th Period 2 Sept 15th Period 1 Sept 15th Period 2

Friday Short Term

Sept 9th Period 1 Sept 9th Period 2 Sept 16th Period 1 Sept 16th Period 2

Monday Short Term

Sept 12th 1st Period Sept 12th 2nd Period

AM Programs from Sept 6th - June 30th 2017 - $8.00/day. Please check all that apply.

Regular Programs

Please select your Preferred program - one program per period.

Regular Programming. starts September 19th and goes to June 23rd, 2017, $11.25/hr to a maximum of $90/week. Only one selection per column.

Ace Reserves the right to change or cancel programs as neccessary.

ACE Registration

Please select your Preferred program - one program per period.

1st Period

Monday

Tuesday

Wednesday

Thursday

Friday

2nd Period

Monday

Tuesday

Wednesday

Thursday

Friday

Please select your Alternate program - one program per period.

1st Period

Monday

Tuesday

Wednesday

Thursday

Friday

2nd Period

Monday

Tuesday

Wednesday

Thursday

Friday