Segal Academy - Registration Form

Student First Name
Student Last Name
Date of Birth
Current Age
Grade (2019-2020)

Parent / Guardian information
Parent #1 Name
Parent #2 Name
Address (number, street)
Address (city, province, postal code)
Home Phone
Primary contact number (please indicate which parent/guardian)
Other contact phone number (please indicate which parent/guardian)
Primary parent/guardian email (all Academy emails will go to this address)
How did you hear of the Segal Academy?

Explain if you selected 'other'
By checking this box, you are giving the Segal Centre permission to use photographs of your child(ren) for promotional purposes to promote the Segal Centre and the Academy.
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Camps & Workshops
Please indicate the week and the number(s) corresponding to the camp(s) or workshop(s) you wish to register for: