EDU WEBVOLUTION AGENCY INC. - PROGRAM REGISTRATION FORM

(L) French Street Hall, (B) St. Peter’s Hall, Alma Rd, Bundoora Contact: 0413 449 785 website: www.bqmedu.org

DATE:

Name of Participant:

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Address: …………………………………………………………………………………………………………….

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Age:

Name of your school: (If Student)

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Parent Name(s): …………………………………………………………………………………………………………….

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Telephone: (Home)

(Mobile)

Email address:

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Preferred Programs : 1. Holidays and Weekends Program (Fun learning activities)

2. Community Youth EDUWEB Program: (Digital Adventure in P-12 Learning)

3. Digital Leisure Care Program: (Seniors health promotion program)

Available times and days for participation:

Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays

(B) (B) (B) (B) Lalor(L) Bundoora(B)

Any Medical Information:

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Declaration: I, (Print name) ……..…………………………………………………………………………………………………….

Have read and agree to adhere to all policies and terms and conditions of the program.

Signed by Participant Signed by Program Director