Home Alone Registration November 2018

Home Alone Registration 2018

Thank you for your interest in the YMCA's Home Alone Course.

November Program Dates: Monday's: November 15, 22, and 29th.

Location: YMCA EarlyON Centre - 161 Roger Street, Waterloo

Time: 6:00-8:00pm

Please complete registration form, upon receipt of your registration form you will receive a conformation email to confirm your child's participation in the course and payment information.

If you have any question please call Beth at 519-741-8585 ext 3006.

Question Title

* 1. Child's Name:

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* 2. Date of Birth

Date / Time

Date

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* 3. Parent / Guardian Name

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* 4. Mailing Address / Contact Information

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 5. Relationship to Participant

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* 6. Alternate Emergency Contact

Name

Phone Number

Question Title

* 1. Child's Name:

Question Title

* 2. Date of Birth

Question Title

* 3. Parent / Guardian Name

Question Title

* 4. Mailing Address / Contact Information

Question Title

* 5. Relationship to Participant

Question Title

* 6. Alternate Emergency Contact

Question Title

* 7. Relationship to Participant