Backpack Program Registration

Parent's Information

Parent's Name
Address
Primary Phone #
Secondary Phone #
Email

Child's Information

Child's Name
Child's Age
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