Child's First & Last Name
Parent/Guardian - First/Last Name
Contact Phone Number
Contact E-mail
Contact Address:
Child's Age & Grade
Medical Information: If your child suffers from any allergies regardless of severity, please make this known to us prior to the commencement of the group by emailing to info@chirucounselling.ca. Any medical information you feel is appropriate should be given.If your child carries an Epi pen please make this known to us in case of an emergency. We do not take responsibility for the administration of the Epi pen in an emergency situation.
Emergency Contact Details:
Payment Method Selected