Segal Academy - Registration Form



Student First Name
Student Last Name
Date of Birth
Current Age
School
Grade (2020-2021)
Allergies

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)

Emergency Contact other than parent/guardian
Name
Phone Number
Relation
How did you hear of the Segal Academy?



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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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In-person courses

Please select at least one course in order to register for in-person courses





Virtual Courses

Please select at least one course in order to register for virtual courses









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