Hampstons Enrollment Form
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Family
Family Name
First Parent
Relation to Child
First Name
Last Name
Email
Cell Phone
Home Phone
Address
City
Province
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Prince Edward Island
Saskatchewan
Ontario
Quebec
Yukon Territory
Postal Code
Personal Email Address
Work Name
Work Phone
Birthdate
Second Parent
Relation to Child
First Name
Last Name
Email
Cell Phone
Home Phone
Address
City
Province
Select Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Prince Edward Island
Saskatchewan
Ontario
Quebec
Yukon Territory
Postal Code
Personal Email Address
Work Name
Work Phone
Birthdate
First Child
First Name
Last Name
Birthdate
Sex
Select Sex
Male
Female
Child lives with
Select Child lives with
Both Parents
Mother
Father
Other
Is there a custody agreement?
Select Is there a custody agreement?
Yes
No
School
Select School
Not in school
Attending kindergarten
Attending grade 1 to 6
School Name
Desired Start Date
Program
Select Program
Daycare
Out of school care
Frequency
Select Frequency
Full Time
Part Time
Drop In
Health Care #
Physician's Name
Physician's Phone
Diet Restrictions
Allergies
Other Medical Concerns
Is the child immunized?
Select Is the child immunized?
Yes
No
Does your child require medication, or carry emergency medication?
Select Does your child require medication, or carry emergency medication?
Yes
No
Subsidy
Select Subsidy
Subsidy is approved
I have applied for subsidy
I will apply for subsidy
I need help applying for subsidy
I do not plan to apply for subsidy
Other questions, comments or notes
Second Child
First Name
Last Name
Birthdate
Sex
Select Sex
Male
Female
Child lives with
Select Child lives with
Both Parents
Mother
Father
Other
Is there a custody agreement?
Select Is there a custody agreement?
Yes
No
School
Select School
Not in school
Attending kindergarten
Attending grade 1 to 6
School Name
Desired Start Date
Program
Select Program
Daycare
Out of school care
Frequency
Select Frequency
Full Time
Part Time
Drop In
Health Care #
Physician's Name
Physician's Phone
Diet Restrictions
Allergies
Other Medical Concerns
Is the child immunized?
Select Is the child immunized?
Yes
No
Does your child require medication, or carry emergency medication?
Select Does your child require medication, or carry emergency medication?
Yes
No
Subsidy
Select Subsidy
Subsidy is approved
I have applied for subsidy
I will apply for subsidy
I need help applying for subsidy
I do not plan to apply for subsidy
Other questions, comments or notes
First Contact (Emergency)
Relation to Child
First Name
Last Name
Cell Phone
Home Phone
Address
City
Province
Select Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Prince Edward Island
Saskatchewan
Ontario
Quebec
Yukon Territory
Postal Code
Authorized for Pickup
Select Authorized for Pickup
Yes
No
Second Contact (Emergency)
Relation to Child
First Name
Last Name
Cell Phone
Home Phone
Address
City
Province
Select Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Prince Edward Island
Saskatchewan
Ontario
Quebec
Yukon Territory
Postal Code
Authorized for Pickup
Select Authorized for Pickup
Yes
No
Wrap Up
How did you first hear about us?
Select How did you first hear about us?
Web Search
Word of Mouth (referral)
Drive by (saw the signs)
Other
Your email address