Registration - Apecton Learning

Registration Form

Parent/Guardian Name *

First

Last

Address *

City *

Parent/Guardian Email *

Parent/Guardian Mobile Phone *

Parent/Guardian Home Phone

2nd Parent/Guardian Name

First

Last

2nd Parent/Guardian Email

2nd Parent/Guardian Phone

Child's name *

First

Last

Preferred Name (nickname)

Child's date of birth *

Child's Additional Information

Alergies, medical conditions, etc. that we should know of.

2nd Child's name

First

Last

2nd Child's Preferred Name (nickname)

2nd Child's date of birth

2nd Child's Additional Information

Alergies, medical conditions, etc. that we should know of.

3rd Child's name

First

Last

3rd Child's Preferred Name (nickname)

3rd Child's date of birth

3rd Child's Additional Information

Alergies, medical conditions, etc. that we should know of.

Emergency Contact/Authorized Pickup Name *

First

Last

Note: A photo ID will be required before the child is released into the custody of an adult other than the parent(s)/guardian(s) who dropped the child off.

Emergency Contact/Authorized Pickup Phone *

2nd Emergency Contact/Authorized Pickup Name

First

Last

2nd Emergency Contact/Authorized Pickup Phone

Programs Registering For (Check all that apply) *

Winter Camp, Session 1, Dec 26-Dec29
Winter Camp, Session 2, Jan 1-Jan 5
LEGO Robotics Workshop, Session 2
Robotics & Programming I, Session 2
Robotics & Programming II, Session 2

Permission & Agreement *

I agree and give my permission

I have read and agreed to the permissions selected above in pursuant to all the terms and regulations that apply.

Payment Method *

E-Transfer to info@apectonlearning.com
Cheque to "Apecton Enterprises Corp"
Cash

Credit Card

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