Registration Form Leave this field blank GENERAL INFORMATION (optional) Choose Daycare: (optional) Little Treasures Children Centre School at Fatima Blind River Early Learning Centre Au Jardin de Pierrot Garderie Nouveau Depart Admission Date: (optional) Discharge Date: (optional) Arrival Time: (optional) Departure Time: (optional) Request days of attendance (optional) Monday Tuesday Wednesday Thursday Friday * (optional) Socialization (8:30 – 11:30) Half Day (5 hrs or less) Full Day (5 hrs or more) Before After School PD Days/school holidays Child's Name (optional) Date of Birth: (optional) Sex: (optional) Male Female Languages (optional) French English Other Address: (optional) Postal Code: (optional) Email: (optional) Home Telephone: (optional) Mother's Name: (optional) Date of Birth: (optional) Home Address: (optional) Workplace (optional) Postal Code: (optional) Work Address: (optional) Home Tel #: (optional) Work Tel #: (optional) Cell #: (optional) Father's Name: (optional) Date of Birth: (optional) Home Address: (optional) Workplace: (optional) Postal Code: (optional) Work Address: (optional) Home Tel #: (optional) Work Tel #: (optional) Cell #: (optional) MEDICAL INFORMATION (optional) Family Physician: (optional) Address: (optional) Telephone: (optional) It is prohibited under the Personal Health Information Protection Act (2004) to collect your child’s health card number. However, you may voluntarily provide it so that it is on file in the event that it is required in an emergency. (optional) Yes No Name Appearing on Card: (optional) Health Card # (optional) Expired Date: (optional) ALLERGIES (optional) Does your child have any allergies? (optional) Yes No If Yes, to what? (optional) Reaction? (optional) Treatment: (optional) Are your child’s immunizations up to date? (optional) Yes No Note: attach a copy of immunization record If no, explain (optional) Does your child have any known health problems? (optional) Yes No If yes, please explain (optional) Do you have any written instructions for any medical treatment or medication to be administered during hours child receives care? (optional) Yes No If yes, decribe medical condition: (optional) Name of Medication: (optional) Dosage: (optional) Note: administration record sheet to be signed Times of administration: (optional) Do you have any concerns about your child’s development? (optional) Yes No if yes, please comment (optional) Are there any holidays you DO NOT want your child to celebrate? (optional) Yes No If yes, please describe: (optional) Safe Sleep procedures have been reviewed with parents/guardians if applicable? (optional) Yes No Non-applicable What are your child’s sleeping habits? (optional) MEDICAL TREATMENT CONSENT (optional) In the event of an emergency, do we have permission to take your child to the hospital by taxi or ambulance at your own cost and agree that when I cannot be reached, that my child receives any medical procedure deemed necessary by any licensed emergency medical services professional. (optional) Yes No EMERGENCY CONTACTS (optional) Name: Relation: Home Tel #: Work Tel #: Name Relation: Home Tel #: Work Tel #: Is there anyone else to whom your child may be released to? Yes No If yes, give names NUTRITION **Infants/Toddlers – it is highly recommended that children up to the age of 2 yrs. of age drink homogenized milk. Please indicate which milk your child is to consume while attending our centre. Homogenized 2% Formula A.S.Q. Ages & Stages Questionnaires is a monitoring program for children 4 months to 5 years we use to ensure your child is progressing well as a first step in early intervention. Do you give us permission to apply this great tool for your child? Yes No PHOTOGRAPHY RELEASE CONSENT I allow my child to be photographed at any time and allow that picture to be published in any newspaper. Yes No Do you have any comments or information which you feel might be helpful in understanding your child? (optional) Text Submit Form
