Inscription 1 activité enfant 3-12

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Person filling out the form

First Name of the person filling this form

Last Name of the person filling this form

Email

To which e-mail address should we send the service confirmation?

Person in charge of registration phone number

Participant 1 Information

First name

Last name

Date of birth

Participant 2 Information

Please tell us the first name and date of birth of the brothers and sisters who will accompany your autistic child during the respite time.

If the information is not provided, we will consider that the request only includes your autistic child and we will not have resources to accommodate other children in the family.

First name (participant 2)

Date of birth (participant 2)

Participant 3 Information

First name (participant 3)

Date of birth (participant 3)

Participant 4 Information

First name (participant 4)

Date of birth (participant 4)

I want to register my child for Evening Respite offered on Friday

Respite is offered

Once a month
on Friday from 5 pm to 9 pm
From September 22d to December 20th, 2025
Cost: $15 per evening

Child Friday evening respite

Yes

No

I want to register my child for Day Respite offered on Saturday

Respite is offered

Once a month
on Saturday from 9 am to 1 pm (group 1) or from Noon to 4 pm (group 2)
From September 22d to December 20th, 2025
Cost: $15 per day

Child Saturday Respite options

Yes, from 9 am to 1 pm (group 1)

Yes, from Noon to 4 pm (group 2)

Yes, one of both groups is OK. I'm flexible.

No

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