| Name: |
| Age: |
| Parent Name: |
| Contact Telephone Number: |
| Please circle the appropriate weeks or days |
| Week 1 | or |
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Fri | |
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| Week 2 | or |
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| Week 3 | or |
Mon | Tue | Wed | Thu |
Fri | |
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| Week 4 | or |
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| Week 5 | or |
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| Total Cost: |
| Please make cheques payable to T. Wilkinson |