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Grey Bruce County Summer Registration

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- Step 1 of 5

Child's Name *

First

Last

Child's Date of Birth *

Child's Age *

How did you hear about us? *

From a friend
Social Media
Word on the street
Newsletter
Referral from an organization
Google search
Other

Referred by

Preferred pronoun

She / Her
He / Him
They / Them
Prefer Not To Say

Please choose your program(s) below

PA Day - June 7th
July 15th - July 19th
July 22 - July 26th
July 29th - August 2nd
August 6th - August 9th (4 Days)
August 12th - August 16th

Before and After care

Before care; 8am-9am ($40/week)
After care; 4pm-5pm ($40/week)

If you have a group or are interested in a day/time that is not listed above, please provide this information here. Please note, we will do our best to accommodate your request. If the program you are interested in is full, we will add you to the waitlist and let you know when a spot opens up.

Parent/Guardian Information *

First

Last

Preferred pronoun

She / Her
He / Him
They / Them
Prefer Not To Say

Email *

Phone number *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent/Guardian 2 Information

First

Last

Preferred pronoun

She / Her
He / Him
They / Them
Prefer Not To Say

Phone number

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Relationship to Child

Approved Names for Pickup (please separate names with a comma)

Does your child have any food, medication or environmental allergies *

Please list and explain any allergies

Does your child's allergy require an Epi Pen

Does your child have a special health or medical condition?

Please explain here any special health or medical condition.

Please provide any additional information about your child that would be useful for Roots 2 Rise staff to be able to best support your child's needs (i.e. emotional, cognitive, behavioural, physical, etc.)

Name *

First

Last

Email *

Date / Time

Code

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