Registration Form

1. 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