Child Enrolment Form

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Thank you for choosing Little Bear Dayhome Agency and for completing this pre-enrollment form!

Please complete all of the fields below. This information is needed prior to your child enrolling in the program. To avoid delays, please complete and submit this form at least 5 days prior to your scheduled enrollment.

To schedule an enrollment date, or to contact the office with any questions, please call

(w) 403-942-1129 or email: littlebeardayhomes@gmail.com. Thank you!

Families meet with an Educator and have the opportunity to ask pertinent questions, ensuring that the family day home is the correct fit. By completing the following Enrolment paperwork, Enrollees indicate that they are comfortable with the environment, and agree to abide by Hours of Operation, Policies & Procedures, and would like their child to attend care with the Educator. Further information is provided in Childcare Contract, Enrolment Forms, and Handbooks. Please select the location are you Enrolling in care for? *

Lethbridge North

Lethbridge South

Lethbridge West

Coaldale

Nobleford

Raymond

Other:

Required

Child's Name *

Anticipated Start Date *

Primary Contact Email Address

Please note that this email will be used for communication with the agency and educators. Items such as newsletters or other communication documents regarding contract updates, program updates, legislation, standards, or funding updates as well as special events may be emailed out. Tax receipts are emailed yearly to this address. Please update the Agency if email information changes.

Child's Home (Physical) Address (Please Include Postal Code, Include PO Boxes if applicable for mailing purposes)
*

Child's Birth Date
*

YYYY

Alberta Health Care Number
*

Doctor's Name
*

Clinic Name and Address & Phone Number
*

Does a Non-Contact Order Exist? (Please bring a copy if YES) *

Yes

Hours of Care must fit within your specific Educator's Hours of Operation, and fall within following chosen FT / PT / Drop In Criteria. Rates are outlined as declared on Educator Rate Declaration. Agency will send a copy of Educator Rate Declaration & Hours of Operation with Enrolment Materials. Please note Holiday Closures outlined on Hours of Operation are not eligible for rebates. *

Full Time Care (Planned 100 - 181 hours per month)

Part Time Care (Planned 8-99 h per month)

Before or After School Care (School Year Only, Grade 1+)

Drop In Care (maximum of 2 months, no more than 16 hours per month - to be used short term for unusual circumstances only)

Overtime Care (Planned 181+ hours per month) * availability is dependent on Educator, please have a conversation with your Educator if you require more than 181 hrs of care per month prior to completing enrolment paperwork. Full time care is up to 181 hrs per month. Additional fee charged by and paid directly to educator as agreed. Special Rate Agreements will need to be signed.

Extended Hour Care (after 6pm or before 6am)*currently not offered by any educators

Required

Days and Time Requiring Care:
*

Do you qualify for Child Care Subsidy? If the amount is known, please include it here:

Family Dynamics/ Home Life/ Circumstances

Specialists & Health Team Members (if Applicable) Please include Name, Specialist Field and Phone Number Below:

Please state any Medical History & Special Information we should be aware of
*

Are you currently attending a child care program?
*

Day Care

Licensed Day Home

Unregulated Care

Not Attending a Program

Does Your child have any allergies? If yes, please list them below
*

Immunizations: It is strongly recommended that all children be immunized against diphtheria, whooping cough, tetanus, polio, red measles and chicken pox – this can be arranged through the Health Unit. All parents are required to sign a section in the contract regarding their child’s current Immunization Record / Status. Parents who elect not to share this information are protected under privacy laws, however, Program Educators may choose not to accept children into their home or childcare program if parents are unwilling to communicate this information.
*

My Child's immunizations are up to Date

My Child's Immunizations are Behind Schedule, but Child Will Receive Immunizations

My Child has Some Immunizations, but will not receive any additional immunizations

I prefer not to provide this information

Is Your Child on Any Emergency or Regular Medications? *

Yes

Other:

Please List any Emergency Medications below (Epi-pens, Inhalers). All Medications left at the family day home must have the child's name, directions, and expiry date. An Educator may not accept any medication unless a signed permission form is on site.

Emergency Contact Information. A minimum of three emergency contacts (including parents) are required due to ministry standards. Please include the three (3) people you would like included as Emergency Contacts on your enrollment information below

Emergency Contact 1 (enrolling party) *

Mother

Father

Grandmother

Grandfather

Guardian

Other:

Emergency Contact 1 Name *

Emergency Contact 1: Address
*

Same as Child

Other:

Emergency Contact 1: (Home and Cell Please) *

Emergency Contact 1: Work Name *

Emergency Contact 1: Work Address (Physical address please) *

Emergency Contact 1: Work Phone

Emergency Contact 2 *

Mother

Father

Grandmother

Grandfather

Guardian

Other:

Emergency Contact 2 Name *

Emergency Contact 2: Address
*

Same as Child

Other:

Emergency Contact 2: (Home and Cell Please) *

Emergency Contact 2: Work Name *

Emergency Contact 2: Work Address (Physical address please) *

Emergency Contact 2: Work Phone
*

Emergency Contact 3 *

Mother

Father

Grandmother

Grandfather

Guardian

Other:

Emergency Contact 3 Name *

Emergency Contact 3: Address
*

Same as Child

Other:

Emergency Contact 3 (Home and Cell Please) *

Emergency Contact 3: Work Name *

Emergency Contact 3: Work Address (Physical address please) *

Emergency Contact 3: Work Phone
*

Additional People Authorized to Pick Up Child (Full Name and Relationship please). These individuals will be listed on enrolment paperwork as able to pick up, but will not be contacted in case of emergency (unless requested). Please note that the Educator must request ID unless previously introduced.

Pets in Family Dayhome - Please note that parents view home prior to enrolment and should discuss pets and animals with the Dayhome Educator. If you are unsure of the animals in the home, please contact your potential educator prior to enrolment date. Please note that Educators may choose to adopt new pets while families attend their day home. Please ensure to share objections to any pets by communicating with your Educator.
*

Fish / Aquarium Animals OK

Small Dogs OK

Large Dogs OK

Cats OK

Reptiles & Snakes OK

Prefer No Pets

Required

Educators often transport to schools, parks, Family Centres, and other locations. Please discuss transportation with your Educator prior to signing enrolment paperwork as Educator may not be able to accommodate transportation request.
*

My child may be transported via educator vehicle, public transportation & walking / biking

My child may be transported walking / biking only

My child may not be transported

Parents may view the Educator's profile at the agency office any time. Enrolments are now completed digitally. If you would you like to make an appointment to view the Educator Profile prior to enrolment, please indicate this and list availability below
*

Please note: Parents should discuss questions regarding residents of the home, pets & animals, educator's children, or areas of concern with their chosen Educator during the interview process. Parents who compete enrolment paperwork indicate that they are comfortable with placing their child in that Educator's home, and that she is able to meet their needs. Are you comfortable with the educator and the dayhome environment?
*

Yes

Please feel free to include any additional information below. Parents will have the opportunity to fill out Family Culture information in detail as part of the digital enrolment process completion. Thank you, we look forward to connecting with you shortly!

If you are enrolling additional children, please complete section 2 / 3. If Emergency contacts are different, please complete a second full enrolment form.

Complete Child 2 Information

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