PACT Program Registration Form

Please print this page, fill it in, and either mail it to PACT with a cheque, mail it to PACT after paying using the PayPal button for the location/session of your choice, or bring it in person to the first morning of the session you are registering for with payment (cheque or cash). Thank you! If you have any questions, please contact PACT via phone: 403-671-1710 or email: P_A_C_T@hotmail.com.

PACT 12 Hawkridge Place NW Calgary, AB   T3G 3A4

PACT Program Location:
Session:	Winter   _______        Spring   _______      Summer ________     Fall _______
Family Name:
Attending Adult’s Name:	Relationship to Child(ren):
Address inc. Postal Code:
Home Phone Number:	Emergency phone number:
Email:
Child's Name:	Birthdate:	Sex:	Allergies/Special Concerns:

Conditions of Registration:

·       Participants are expected to interact with the children at an activity centre on a weekly basis or to participate in the discussion group, and are requested to help out with facility cleanup, including a once-per-session Toy Wash.

·       There will be no refunds given after the first morning.

·       There is a $25 service charge on all NSF cheques.

·       Full refund will be given 3 days prior to program start.

·       Additional fees are charged for babysat children who attend with a registered family.

·       Snacks are provided each week (parents take turns providing snack)

·       Any concerns regarding the program should be addressed to the Parent Educator or the Children's Program Coordinator.

·       PACT assumes no responsibility for loss, damage, injury, ambulance service or the use of information received.

 

I have read and understood these conditions and accept them as part of my registration.

 

______________________________                                    ______________________________

Participant Signature                                                                Today's Date

 

$175 per family per session; $285 if registering for two programs/mornings per week (please contact PACT via phone or email if you are interested in this discounted price & in registering for two mornings)

 

Fee Paid: __________ Cash/Cheque/PayPal _____ (circle)       Date _________         

Fee Paid: __________ Cash/Cheque/PayPal _____ (circle)       Date _________   Cheque(s) made payable to PACT

Fee Paid: __________ Cash/Cheque/PayPal _____ (circle)       Date _________

 

$90 per family Summer session Fee Paid: _________ Cash/Cheque/PayPal ____ (circle) Date _________

Summer session only:   please indicate weeks attending   wk 1 ___   wk 2 ___   wk 3 ___   wk 4 ___   wk 5 ___   wk 6 ___

 

I heard about PACT from:

(word of mouth, Calgary's Child magazine, community newsletter, Health Clinic, TV, other?)

March 14, 2011