Participant information

Please fill out the following form. For any questions, please contact Linda Alfonsi De Fazio by phone at 514-279-3666 ext. 206 or by email at Lindad@yaldei.org. Please note that you will also be asked to provide a recent photo of your child for their ID.

Child's Name *
Child's Name
Date of Birth
Date of Birth
Sex
Communication
Father's Name
Father's Name
Mother's name
Mother's name
Emergency Contact person
Emergency Contact person
2nd Emergency Contact person
2nd Emergency Contact person
Cardiac Problems?
Epilepsy?
Asthma?
Coagulation problems?
Please specify.
Please specify.
Epipen
Please provide a list of all medications, PRN, medication sold over the counter, vitamins, etc. (If there are several medications, you can attach a list). Please provide the name and the telephone number of the pharmacy. Please note: Medication taken during program hours must be sent in a clearly labelled Dosset box. We must have written notification of any medication changes when they occur.