Segal Academy - Registration Form

Student First Name
Student Last Name
Date of Birth
Current Age
Grade (2021-2022)
Does your child take medication? (Ritalin, Ventolin, insulin, etc.)? If yes, which one(s) and for what ailment/diagnosis?
Please note any physical or emotional condition of which we should be aware, so that we may have a better understanding of your child.

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'

Emergency Contact other than parent/guardian
Phone Number
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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Please select at least one course in order to register: