Register - Carre Four 6-12

Identification of the child

Name of the child *

First

Last

Gender of the child *

Female
Male

Date of Birth *

Health insurance number

Card expiration

Child's address

Address of the child *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number (Home)

Language(s) spoken at home

Mother

Name of the mother

Email (mother)

Cellphone (mother)

Tel Work (mother)

Father

Name of the father

Email (father)

Cellphone (father)

Tel Work (father)

Information about the parents

Family origin

Social Status *

Mother/Father Single Parent
Couple/ or Married

Marital status *

Resident
Canadian Citizen
Refugee claimant
Humanitarian refugee

Family income *

0 à $15,000
$15,000 à $30,000
$30,000 à $45,000
$45,000 and more

Number of people in the household *

Occupation *

Work
Education
Employment Insurance
Social assistance

Level of education *

University
Professional
College
Other

Please provide the 2019-2020 tax notice when you come to Carrefour 6-12 to sign the registration

Emergency contact person (other than mother or father)

Name of the person *

Phone *

Link with the child *

School attended

School

Other

Class number

Teacher's name

Level

Medical card This sheet is important. It allows us to ensure a safe stay for children and to know what special attention to give them.

Does your child have any illness? Allergies? If so, name it and indicate if there are any medications to take as well as the dosage *

Details of illness

Does he need special attention on the behavioral level? If yes which one ? *

Detail of behavior

Does your child have to follow a specific diet? If so, which one (eg no pork)? *

Detail of specific diet

Does your child attend another organization? If so, which one? And what service does he/she receive? (Homework help, reading, music, art ...) ? * *

Other Organization

What activity would you like to register your child for

School accompaniment
Sport (basketball and soccer)
Theater workshop
Art workshop
Music lessons
Children's rights
Summer camp

Do you have any other information you would like to share with us

Authorization and release

I, the undersigned, declare that the child named above is a minor child and is under my legal responsibility.
I, the undersigned, declare that I am fully aware of the risks and perils inherent in the activities, that I accept the provisions relating to supervision and that I authorize the child named above to participate in the activities .
FOR MEDICAL EMERGENCIES. All decisions regarding the medical care provided to my child will be communicated to me as soon as possible in order to obtain my consent. In the event that it is impossible for the manager to reach me, I authorize him to intervene on my behalf. In addition, in a serious emergency, I authorize the attending physician to perform any medical treatment with the aim of treating or saving the life of my child.
I, the undersigned, authorize the Carrefour des 6-12 to photograph, or film, from time to time, my child as part of their activities. The photographs will be used for souvenir albums as well as to promote our organization to funders.
I am committed, as a parent, to making sure the child arrives on time for activities. I make sure to pick him up when the activity ends. I will take the necessary steps to fulfill my commitment, otherwise I agree to pay the fee of $ 5.00 (five dollars) for every 15 (fifteen) minutes late.

Membership application 2021-2022!

There is a refund ONLY when the Carrefour cancels its activities.

nos partenaires

4773 boul. Lalande Pierrefonds, Québec H8Y3H4

514-685-9598