A:
STUDENT'S NAME
DATE OF BIRTH
AGE
B:
Are there any medical or special circumstances affecting
the student of which we should be aware? Please Specify
C:
PARENT OR GUARDIAN'S INFORMATION
Name:
Home Phone:
Work Phone:
Email Address:
D:
MAILING ADDRESS
Address:
City:
Province:
Postal Code:
E:
HOW DID YOU COME TO KNOW US?
Previously Registered
Stoney Creek News
Internet
Brochure
Hamilton Spectator
Relative, Friend, etc.
Yellow Pages
Other:
F:
LLDS LIMITED AND ITS EMPLOYEES OR AGENTS SHALL NOT BE HELD LIABLE FOR ANY INJURY SUFFERED OR AGGRAVATED BY THE STUDENT WHILE UNDER INSTRUCTION AND OR PERFORMING WITH LLDS LIMITED. PARENTS ARE SOLELY RESPONSIBLE FOR ENSURING THAT STUDENTS CONSULT A PHYSICIAN FROM TIME TO TIME REGARDING THEIR PHYSICAL CONDITION.
G:
THE UNDERSIGNED HAS READ AND UNDERSTANDS THIS DOCUMENT AND CERTIFIES THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT, AND FURTHER AGREES TO ABIDE BY ITS TERMS AND CONDITIONS AND THE RULES AND REGULATIONS ATTACHED.
Date:
Name: