Early Head Start Registration Form - NDG
Please fill out all the boxes below to register for the Early Head Start Program
Email address *
Child's name (first and last)
Your answer
Child's current address: street name, number, and apartment number *
Your answer
City *
Your answer
Province *
Your answer
Postal code *
Your answer
Telephone number *
Your answer
Child's age
Your answer
Child's date of birth *
MM
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DD
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YYYY
Child's gender *
Preferred language of communication *
Your answer
Does your child have any allergies or health concerns we should be aware of?
Your answer
Parent/Guardian 1 name (first and last) *
Your answer
Parent/Guardian 2 name (first and last)
Your answer
Number of classes a week you'd like to attend
Please check off which days you would like to participate in the program (all classes are from 10am-12pm)
If there is anyone other than a parent or guardian who will be picking up your child at anytime, please list their name, phone number, and relationship to your child below:
Your answer
In case of emergency please contact: Name (first and last) *
Your answer
Relationship to child *
Your answer
Phone number *
Your answer
Is there anything else you would like us to know about your or your child?
Your answer
Collective Community Services Photo Authorization *
Today's date *
MM
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DD
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YYYY
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