YMCA of Moose Jaw
St Margaret Early Learning Centre
Pre-Registration Form
Personal Information
Parent Name:________________________________________________________________
Child’s Name:________________________________________________________________
Child’s Date of Birth: ______________________________________ (Day/Month/Year)
Address:________________________________________________
_______________________________________________________
_______________________________________________________
Home Phone: (______) ________ ____________
Business Phone: (______) _______ ___________
Cell Phone: (______) _______ _______________
Parent email address:
___________________________________________________________________________
Has your child/ren ever been involved with any outside agencies? YES/NO
If YES, please identify:
___________________________________________________________________________
I prefer my child to attend:
part time (2-3 half days a week)
OR
 full time (5 half days a week)
A.M. 8:30-11:00
A.M. 8:30-11:00
P.M. 12:15-2:45
P.M. 12:15-2:45
Signature:________________________________ Date: ____________________________