EASTRIDGE VBC 2010 WAITING LIST SIGNUP

Parent’s Name:

Address:

Phone:

E-mail:

Province

City:

Postal Code

Child 1 Name:

Child 2 Name:

Age:

Age:

Age:

Child 3 Name:

Grade Sept.2010:

Grade Sept.2010:

Grade Sept.2010:

Allergies:

Activity Group with:

Allergies:

Activity Group with:

Allergies:

Activity Group with:

Home Church:

Name of Approved Alternate Pickup:

Emergency Phone: