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Child Registration Package
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* Indicates required question
Child's Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Estimated Time of Arrival
*
Your answer
Estimated Time of Arrival
*
Your answer
Start Date
*
MM
/
DD
/
YYYY
Office Use Only
Option 1
Clear selection
Start Date
*
MM
/
DD
/
YYYY
End Date
*
MM
/
DD
/
YYYY
Deposit paid
*
yes
No
Deposit policy signed?
*
Yes
No
Amount paid
*
Your answer
Date paid
*
MM
/
DD
/
YYYY
Child’s Emergency Information
Child’s Name:
Date of Birth
*
MM
/
DD
/
YYYY
Home Address
*
Your answer
City/Province
Your answer
Postal Code
*
Your answer
Parent/Guardian Information
First Name
*
Your answer
Last Name
*
Your answer
Home Address
*
Your answer
City/Province
*
Your answer
Home Phone
*
Your answer
Cell Phone #
*
Your answer
Workplace
*
Your answer
E-mail Address
*
Your answer
Emergency Contacts (Must be 18 years or older)
First Name
*
Your answer
Last Name
*
Your answer
Home Address
*
Your answer
City/Province
*
Your answer
Home Phone
*
Your answer
Cell Phone
*
Your answer
Workplace
*
Your answer
E-mail Address
*
Your answer
Name of Additional persons to whom the child MAY be released
*
Your answer
Name of the Person(s) to whom the child MAY NOT be released:
*
Your answer
Child’s Medical Information (complete all fields)
Health Care Number
*
Your answer
Doctor’s Phone #
*
Your answer
Medical Concerns
*
Your answer
Allergies/Dietary
*
Your answer
Are your child’simmunizations up to date?
*
Yes
No
Does your child take ongoingmedications?
*
Yes
No
If yes, please specify:
*
Your answer
Custodial arrangements/orders
*
Your answer
Date
*
MM
/
DD
/
YYYY
Parent Signature
*
Your answer
Child’s Background Information
Favourite Activities
*
Your answer
Fears (if any)
*
Your answer
Dislikes (if any)
*
Your answer
Reaction to stress
*
Your answer
Previous child care experience
*
Your answer
Sleep Pattern
*
Your answer
Physical Goals
*
Your answer
Personal Goals
*
Your answer
Pets (if any)
*
Your answer
What languages are spoken in your household?
*
Your answer
What holidays and traditions are celebrated in your household? How do you celebrate them?
*
Your answer
How can we validate and support your family’s lifestyle here at the centre?
*
Your answer
Other children in the family Name & Relation
*
Your answer
How does your child react to new environments?
*
Your answer
Child’s reaction to being tired?
*
Your answer
Child’s reaction to illness?
*
Your answer
Child’s reaction to stress?
*
Your answer
Is your child toilet trained?
*
Your answer
If no, how can we support your child in this developmental area?
*
Your answer
Parent Agreement
Parent Agreement
*
Your answer
*
Your answer
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