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After-School Program

AddAccountMemberSection

First Name Required	First Name, field is required
Last Name Required	Last Name, field is required
Birthday Required	Month:, field is requiredDay:Year:
Email Required	Email, field is required
Primary Phone Required	, field is required
Primary Phone Type	Primary Phone Type, to switch between list items use arrow buttons. Mobile
Mailing Required	Street City Country ProvincePostal code Canada
Gender	Gender, to switch between list items use arrow buttons.
Emergency Contact Phone
Emergency Contact First Name	Emergency Contact First Name
Emergency Contact Last Name	Emergency Contact Last Name
Emergency Contact Email	AdditionalEmergencyContactEmail
Emergency Contact Relationship	Emergency Contact Relationship

Parent and Child’s Identification Record

Childs Full Legal Name
Child’s Preferred Name:	Child’s Preferred Name:
Who has legal custody:	Who has legal custody:
Mother’s Name:	Mother’s Name:
Cell Phone	Cell Phone
Home Address:	Street City Country ProvincePostal code Canada
Father’s Name:	Father’s Name:
Cell Phone:	Cell Phone:
Home's Address	Street City Country ProvincePostal code Canada

Gender	Gender, to switch between list items use arrow buttons.

Health Information

Child’s Physician/ Health resource:	Child’s Physician/ Health resource:
Address	Street City Country ProvincePostal code Canada
Child’s OHIP Number:	Child’s OHIP Number:

Phone:	Phone:

Has Child had.

Surgery	Surgery
Burns	Burns
Convulsion	Convulsion

Serious Illness	Serious Illness
Allergies	Allergies

Concern

Any concern

Signature

Signature of Parent