Application for Admission (Bil)

L’Arbre de Connaissance / The Learning Tree
Demande d’Admission /Application for Admission
Date de début désirée: ________________
5 jours
3 jours
2 jours
Tot Start
(Disponible seulement pour enfants de 18 mois à 3 ans)
Date de visite désirée:_________________
Comment avez-vous entendu parler de L'Arbre de Connaissance ?____________________________________________
Nom de l’enfant: ________________________________Sèxe: ________ Date de naissance: _____________________
Adresse: _______________________________ Ville: ______________________ Code Postal: __________________
Restrictions médicales, maladies, allergies, diète spécial (spécifier): _________________________________________
Avez-vous des souçis concernant des difficultés d’apprentissage ou motrices? (spécifier) : _______________________
________________________________________________________________________________________________
Nom du père: ____________________________ Addresse courriel : ________________________________________
# Tél. Cellulaire: __________________# Tél. maison: _________________ # Tél. Bureau: ______________________
Nom de la mère: _________________________ Addresse courriel : _________________________________________
# Tél. Cellulaire: __________________# Tél. maison: _________________# Tél. Bureau: _______________________
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Desired Start Date : ________________
5 Days
3 days
2 days
Tot Start
(Available only from 18 mths to 3 years)
Desired visiting date:_______________
How did you hear about us?______________________________________________________________________
Child's Name: _________________________________________ Sex: ________ Date of Birth: _______________
Home Address: _________________________________ City : __________________ Postal Code: ____________
Medical Restrictions, Illnesses, Allergies, Special Diets (specify):________________________________________
Do you have any concerns regarding learning or gross/fine motor disabilities? (specify): ______________________
_____________________________________________________________________________________________
Father's Name: ____________________________
E-Mail Address : ____________________________________
Cell #: ______________________Home#:______________________Bus.Tel.#: ____________________________
Mother's Name: ____________________________
E-Mail Address : ____________________________________
Cell #: ______________________Home#:_______________________Bus.Tel.#: ____________________________
_____________________________________________
Signature
__________________________
Date