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Ackermann-Froebel
Enrichment Program

(AFEP)

Ackermann-Froebel Enrichment Program (AFEP)

Inspiring Hearts | Strengthening Characters | Celebrating Achievements | Nurturing Resilience

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Ackermann-Froebel Enrichment Program
Samurai for Children/Youth Enrollment Form

A Samurai is a member of the Japanese warrior class.

AFEP Samurai Children/Youth: Enrollment Form

The information in this form will ensure the AFEP caters to the individual needs of the participant contributing to best outcomes. This information is held in strict confidence and will adhere to our privacy policy.

*Required Fields.

First name*

Last name

First & Last Name of Parent/Guardian*

Email of Parent/Guardian*

Cell Phone of Parent/Guardian*

Emergency Phone of Parent/Guardian*

Address of Parent/Guardian & Child*

Birthday of Child Participant*

Year

Month

Day

Participants School Name*

Grade of Participant*

Name of Physician for Participant*

Contact Information of Physician*

Has the Pre-Admission Assessment Been Completed?*

Yes

No

Unsure

Does the Child Participant Have Siblings?*

Yes

No

What is the Child Participants Birth Order (Eldest, Youngest, Middle)?*

Does the Child Participant Have 2 Parents Living in the Same Household?*

Yes

No

Is the Child Participant currently Under Care of a Physician for Ongoing mental and/or Physical Health Concerns?*

Yes

No

Is the Participant Under Disciplinary Action by Either School or Law Enforcement? *

Yes

No

Has the Participant been Expelled from School or Sports Club?*

Yes

No

Please Highlight Any Allergies the Child Participant May Have*

Please Highlight Any Anxiety the Child Participant May Have*

Is There Any Other Information you Would Like to Share With Us?*

Non-Refundable Payment Which will be Deducted from 1st Months Fees.

$15

Signature of Parent/Guardian*

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Ackermann-Froebel Enrichment Program (AFEP)

Connect with Us

St John's, NL

A1A 4B5

Canada

1-709-341-9231

(After 4:30 PM on Monday-Thursday | All Day Sunday)

info@ackermann-froebelenrichmentprogram.ca

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