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APPLICATION
FORM
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Care Required:
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Start Date Requested:
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Child’s
Information:
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First Name:
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| Last Name: |
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| Sex: |
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| Date of Birth: |
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| Address: |
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| City |
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| Province: |
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| Postal Code: |
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| Home Phone: |
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| Siblings and Ages: |
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| Does the child have any special
diet, rest or exercise requirements? |
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| Parent/Guardian Information:
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| Mother’s Name: |
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| Contact email address: |
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| Phone(h): |
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| Phone(w): |
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| Home Address: |
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| Workplace: |
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| Work Address: |
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| Father’s Name: |
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| Phone(h): |
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| Phone(w): |
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| Home Address: |
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| Workplace: |
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| Work Address: |
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| Signature of Parent/Guardian: |
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| Date: |
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