Stepping Stones After School Program

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Stepping Stones After School Program

This form should be filled in by the parent who will receive the Relevé 24 at the end of the year (Parent/Guardian Contact #1)

Please note that all fields marked with a red asterisk (*) are mandatory.

How many children will you be registering?*

Parent/Guardian Contact #1

First Name*

Last Name*

Address*

City*

Postal Code*

Email Address*

Home Phone #

Work / Cell Phone #*

Relationship to the child*

Releve 24 Information

Would you like to receive a Releve 24 at the end of the year?*

Yes

No

If you have answered "Yes", please provide your Social Insurance Number (SIN)

Please note that no Releve 24 can be issued without a valid SIN. Releves 24 will be sent out on or before February 28, 2021.

Parent/Guardian Contact #2

First Name*

Last Name*

Home Phone #

Work / Cell Phone #*

Email Address*

Relationship to the child*

First Child

First Name*

Last Name*

Gender*

Male

Female

Preferred language*

French

English

Birth Date (DD-MM-YYYY)*

Medicare Number*

Does your child have any allergies?*

Yes

No

If you have answered "Yes", please elaborate.

Does your child take any medication?*

Yes

No

If you have answered "Yes", please elaborate.

In order for Stepping Stones to best accommodate your child, is there any other medical history or condition that we should be made aware of, concerning your child?

I understand and agree that photos of my child may be used for promotional purposes. (If you have any questions or concerns about this, please contact Jason Brereton.)*

Yes

No

Child #1 - Week 1 (Nov. 3 & 5)

$30.00 Quantity

Child #1 - Week 2 (Nov. 10 & 12)

$30.00 Quantity

Child #1 - Week 3 (Nov. 17 & 19)

$30.00 Quantity

Child #1 - Week 4 (Nov. 24 & 26)

$30.00 Quantity

Child #1 - Week 5 (Dec. 1 & 3)

$30.00 Quantity

Child #1 - Week 6 (Dec. 8 & 10)

$30.00 Quantity

Child #1 - Week 7 (Dec. 15 & 17)

$30.00 Quantity

Second Child

First Name

Last Name

Gender

Male

Female

Birth Date (DD-MM-YYYY)

Preferred language

French

English

Medicare Number

Does your child have any allergies?

Yes

No

If you have answred "Yes", please elaborate.

Does your child take any medication?

Yes

No

If you have answered "Yes", please elaborate.

In order for Stepping Stones to best accommodate your child, is there any other medical history or condition that we should be made aware of, concerning your child?

I understand and agree that photos of my child may be used for promotional purposes. (If you have any questions or concerns about this, please contact Jason Brereton)

Yes

No

Child #2 - Week 1 (Nov. 3 & 5)

$30.00 Quantity

Child #2 - Week 2 (Nov. 10 & 12)

$30.00 Quantity

Child #2 - Week 3 (Nov. 17 & 19)

$30.00 Quantity

Child #2 - Week 4 (Nov. 24 & 26)

$30.00 Quantity

Child #2 - Week 5 (Dec. 1 & 3)

$30.00 Quantity

Child #2 - Week 6 (Dec. 8 & 10)

$30.00 Quantity

Child #2 - Week 7 (Dec. 15 & 17)

$30.00 Quantity

* Please make sure that all information is accurate before submitting.

Checks should be made out to: "Montreal Youth Unlimited", and mailed out to:

298 Brookhaven Avenue

Dorval, QC H9S 2N4

E-Transfers should be sent to: paiements@jslmontreal.org. Please indicate "Terra Nova - Stepping Stones" in the "Comment" section.

Payment Type

Total

Head office located at:
298 Brookhaven Avenue
Dorval, QC H9S 2N4

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