Contact Information Form Winnipeg School Division printable pdf download

CONTACT INFORMATION

Child’s name:___________________________________________________________________________________________________________

Please indicate which programs your child(ren) will be attending (circle all that apply)

Lunch Program

Before-School

After-School

Primary Contact Name:

Secondary Contact Name:

Address: _____________________________________________

Address: ___________________________________________________

Home Phone Number: __________________________________

Home Phone Number: ________________________________________

Work Phone Number: __________________________________

Work Phone Number: ________________________________________

Cell Phone Number: __________________________________

Cell Phone Number: ________________________________________

Email: _______________________________________________

Email: _____________________________________________________

Alternate Care (Name and Relation): ______________________________________________________

Home Phone Number: _____________________ Address: ____________________________________

Work Phone Number: _____________________

Cell Phone Number: ___________________________

I acknowledge that my child(ren) fully understand the rules and behaviour expectations as detailed in the Handbook (available in the General Office

and at ) and that my child(ren) will abide by those rules.

Parent/Guardian Signature: _______________________________________ Date: ________________

†

Volunteer workers at the Lunch Program must complete a Child Abuse Registry Form.

Does your child have a Health Care Plan (HCP) at École Riverview School? (please circle)

YES

I ____________________________ give permission for École Riverview School to share _______________________’s HCP with the Before Lunch

After School Programs (BLAS).

I also give permission for my child’s photo to be displayed as one of the children with a HCP. (please circle)

YES

Parent/Guardian Authorization _________________________________________

Questions or concerns regarding the BLAS programs may directed to

or by calling 204-284-5444

Contact Information Form Winnipeg School Division