Student Name First Middle Last Address Street City Postal Code Date Of Birth Gender MaleFemale Programs ScratchPythonJavaHTMLCSSJavaScriptSwift PlaygroundMathematicsMicrosoft Office School Name Grade Parent Guardian Information Father's Name Home Phone Number Cell Number Email Mother's Name Home Phone Number Cell Number Email Emergency Contact (To Be Used Only If Parents Can’t Be Reached.) Name Relationship Cell Number Phone Other Siblings YesNo Siblings ScratchPythonJavaHTMLCSSJavaScriptSwift PlaygroundMathematicsMicrosoft Office Name of Brother/Sister Date Of Birth Grade Additional Information How did you hear about us: Friend/ Relative Referral: Name: Phone Media Permission: Publicity and Promotional Opportunities: Your child may be photographed or videotaped while participating in regular learning activities at Code Academy Learning Center. This provides an opportunity for your child to represent the center and/or receive recognition for achievement. Examples may include news releases, program announcements, brochures, and social media, including Facebook, Twitter, and YouTube. Please check the appropriate box and sign and date this form to indicate whether you consent to having your children participate in publicity opportunities. Please read the following carefully before signing I Agree to have my child participate in publicity and promotional opportunities.I Do Not Wish my child participate in publicity and promotional opportunities. Parent Signature Date Credit Card VisaMaster Card Name On The Card Expiry Date (MMYY) - Credit Card Number CVV Purpose of Debit: Debit monthly tuition fees payable to Code Academy Ltd. Terms of Authorization: The above customer authorizes Code Academy Ltd. to debit the above account in the amount of $ +HST on the day of each month. In case the day falls on a Saturday, Sunday or Holiday the funds will be debited on the first work day to follow. NSF Fee: Service charge of $30.00 will be applied to any item returned for insufficient funds(NSF). Cancellation: Code Academy Ltd. Preauthorized Payment can be cancelled at any time by giving 45 days’ written notice to the Code Academy Ltd. Changes in Address or Banking: The customer will notify Code Academy Ltd. Promptly in writing of any changes in person address or banking information. I agree to the Above term and conditions, and have provided accurate banking information for the purpose of PAD for tuition to the Code Academy Ltd. Signature of Authorized Account Holder(s) Date
