2015 HOMEWORK CLUB REGISTRATION FORM Classes will be held on Tuesdays & Thursdays beginning October 6, 2015

Call 905-455-6789 to register or go online at www.unitedachievers.org Registration Fee - $10 STUDENT INFORMATION First Name:

Last Name:

Address:

Apt:

City:

Prov:

Postal Code:

Date of Birth: (DD/MM/YYYY)

Age:

School Attends:

Sex:

M

Grade:

Parent/Guardian’s Name:

Relationship:

Address (if different from above) : Tel: (

)

Cell: (

)

Email:

What are the student’s favourite subjects? What subjects does the student need help with the most? What are his/her major interests:

EMERGENCY INFORMATION Does student have known allergies or medical needs?

Yes:

No:

If yes, please clearly state what they are:

Alternate contact information in case of emergency: Name: Tel: (

Relationship: )

Cell: (

Patient/Guardian signature:

)

Email:

Date (MM/DD/YYYY)

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United Achievers’ Community Services, Inc. 36 Queen Street East, Lower Level, Brampton, ON L6V 1A2  Tel: 905.455.6789  Fax: 905.455.6162 [email protected]  www.unitedachievers.org

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