Mini University Registration Guide 2014 Guide | Page 19

MINI UNIVERSITY 2014 REGISTRATION FORM (PAGE 1 OF 3) REGISTER ONLINE: IT’S QUICK AND EASY! 204-727-7311 [email protected] miniu.brandonu.ca Visit miniu.brandonu.ca and click on “Register Online” Please complete one registration form per child. For multiple children or complex schedules, we recommend using our online registration system. If you attended in 2012 or 2013, you already have an online account created; just update your information, pick your programs, pay, and you’re done! STEP 1) Supply participant information and ALL APPLICABLE CONTACT PHONE NUMBERS: YYYY MM DD Child’s Last Name Child’s First Name Address City & Province E-mail (required for registration confirmations, etc.) Postal Code ( ) Home Phone Primary Contact: Marital Status: Date of Birth  Male  Female School Presently Attending Grade (as of May 2014)  Mother  Father  Other: __________________________  Married  Separated  Divorced  Single FOR THE EXPRESS PURPOSE OF SPONSORSHIP GRANTS, BURSARIES AND STATISTICS, PLEASE CHECK ALL THAT APPLY TO YOUR CHILD/FAMILY:  Aboriginal / First Nation  Métis  Recent immigrant / EAL  Low income ( ) ( ) ( ) Mother’s Name (or Other’s) Mother’s Work Phone + Ext (or Other’s) Mother’s Cell Phone (or Other’s) Father’s Name Father’s Work Phone + Ext. Emergency Contact #1 Name (non-parent) ( ) Father’s Cell Phone Emergency Contact #1HomeorWorkPhone Emergency Contact #2 Name (non-parent) ) Emergency Contact #1 Cell Phone Emergency Contact #2HomeorWorkPhone ( Emergency Contact #2 Cell Phone My child can ONLY be released to... ( ( ) ( ) )  Mother  Father  Emergency Contact #1  Emergency Contact #2  Other (Names/relation: _________________________________________________)  My child is allowed to sign out on their own at the end of their day. Initial: _________  My child is NOT allowed to change courses/programs without my/our permission. Initial: _________ Are there any child custody issues of which Mini U should be made aware?  Yes (Please detail below)  No _____________________________________________________________________ _____________________________________________________________________ Health Information: Please provide details of any allergies, medication requirements, special needs, dietary restrictions or other medical conditions ofwhich weshould bemade aware.Thisinformation willbesharedwithMini University administrators andinstructors. (Attachadditionalsheetsif necessary.) __________________________________________________ ______________________________________________________________________ How did you or your child first hear about Mini U? (Pick one.)  My child attended previous year(s)  Recommended by child’s friend  Recommended by parent’s friend/family  Facebook  Search Engine (Google, etc.)  Twitter  eBrandon  Brandon Sun Ad or Article  Westman Journal Article  Other Newspaper/Media Source (_____________________)  Radio Advertising  Poster at local business  Presentation at School  I Don’t Know  Other: ___________________________________________