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    Student Name




    Parent Guardian Information

    Emergency Contact (To Be Used Only If Parents Can’t Be Reached.)

    Other Siblings

    Additional Information

    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

    Pick Up Authorization

    Student Name


    Other Siblings
    Name of Brother/Sister

    First/Last Name Relationship to child Phone

    Self Signout Authorization:

    Do you authorize your child to sign him/herself in and out of Code Academy?

    If any unauthorized person come to pick up your child, Code Academy staff will contact you at the numbers listed above, and ask for copy of photo Id for security reasons. We will not leave your child with any unauthorized person without prior written notice.

    Credit Card

    Expiry Date (MMYY)


    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.