Act 4

Act 4 Registration

Please complete the form below:

First Name	*
Last Name	*
Parent or Guardian's name	*
Custody or guardianship particulars (if applicable)
Email Address	*
Home Phone Number	*
Work Phone Number
Mobile Phone Number(s)
Emergency Contact
Address

City
Province
Postal Code	*
Date of Birth	*
Grade in School	*

Allergies or Medical Conditions
Comments
How much would you like to pay? ($10-$50/month/child)	*