Backpack Program Registration

    Parent's Information

    Custodial Parent / Guardian Name (First AND Last)
    Address
    Primary Phone #
    Secondary Phone #
    Email

    Child's Information

    Child #1

    Child's Name (First AND Last)
    Date of Birth (DD-MM-YYYY)
    Child's Gender:
    What School Are They Attending?
    What Grade Are They Going Into?


    Child #2

    Child's Name (First AND Last)
    Date of Birth (DD-MM-YYYY)
    Child's Gender:
    What School Are They Attending?
    What Grade Are They Going Into?


    Child #3

    Child's Name (First AND Last)
    Date of Birth (DD-MM-YYYY)
    Child's Gender:
    What School Are They Attending?
    What Grade Are They Going Into?


    Child #4

    Child's Name (First AND Last)
    Date of Birth (DD-MM-YYYY)
    Child's Gender:
    What School Are They Attending?
    What Grade Are They Going Into?


    Child #5

    Child's Name (First AND Last)
    Date of Birth (DD-MM-YYYY)
    Child's Gender:
    What School Are They Attending?
    What Grade Are They Going Into?


    Child #6

    Child's Name (First AND Last)
    Date of Birth (DD-MM-YYYY)
    Child's Gender:
    What School Are They Attending?
    What Grade Are They Going Into?


    Child #7

    Child's Name (First AND Last)
    Date of Birth (DD-MM-YYYY)
    Child's Gender:
    What School Are They Attending?
    What Grade Are They Going Into?




    Consent To Release Information

    I HEREBY GIVE CONSENT TO SHARE MY NAME, DATE OF BIRTH AND DATE OF MY VISIT ONLY FOR THE PURPOSE OF CONFIRMING MY VISIT TO THE SIMCOE HALL SETTLEMENT HOUSE.

    Your personal information is respected and protected, however, information is shared/discussed with other agencies/services in Durham Region. Yes, I give consentNo, I do not give consent



    **You will be contacted via email with a scheduled pick up time within 7 business days.**