Preschool Registration Form

Student's First Name

Student's Last Name

Date of birth (Month/Day/ Year)

Sex Sex Male Female

Does the child have special custody? Does the child have special custody? Yes No

Please specify (e.g mother only, father only)

Does the child have a Legal Guardian? (e.g. Relative or friend) Does the child have a Legal Guardian? (e.g. Relative or friend) Yes No

Student's Legal Guardian (e.g.) relative or friend

Street Address

City

Province

Postal Code

Phone Number

Health Card (optional)

Expiry Date

Mother/Guardian Name

Address

Occupation

Employer/School

Employer/School Address

Marital Status

Home Phone

Work/School Phone

Cell Phone

Email Address

Father/Guardian

Address

Occupation

Employer/School

Employer/School Address

Marital Status

Home Phone

Work/School Phone

Cell Phone

Email Address

Child's Doctor

Street

City

Phone

Province

Postal Code

Special diet:

Allergies:

Medication:

History of communicable diseases:

Emergency Contact & Authorized Pickup Person (Must be over 18 yrs of age) Name:

Phone Number

Relation to the child

Able to pick up all children in the family Able to pick up all children in the family Yes No

2nd Contact/Pick Up

Phone Number

Relation to the child

Able to pick up all children in the family Able to pick up all children in the family Yes No

In the event of an emergency or when prior arrangements have been made, I hereby consent the contacts listed above to pick up my child(ren) from Adelfiha’s Childcare Centre. In the event of an emergency or when prior arrangements have been made, I hereby consent the contacts listed above to pick up my child(ren) from Adelfiha’s Childcare Centre. Yes, give my consent

Please type your name for Signature

Date

As part of our program, from time to time, the staff may find it appropriate to take the children for a walk in the local neighbourhood to nearby parks. Because these walks are often spontaneous, we are subject to existing weather conditions and advance notice is not always possible. Your signature indicates your approval of your child’s participation in these adventures. On the occasion Adelfiha’s Childcare leaves the centre on a field trip, a permission form will be issued with prior notice. As part of our program, from time to time, the staff may find it appropriate to take the children for a walk in the local neighbourhood to nearby parks. Because these walks are often spontaneous, we are subject to existing weather conditions and advance notice is not always possible. Your signature indicates your approval of your child’s participation in these adventures. On the occasion Adelfiha’s Childcare leaves the centre on a field trip, a permission form will be issued with prior notice. I understand the terms.

Please type here for sign your signature

Throughout the year the staff at Adelfiha’s Childcare will be taking pictures of the children involved in many activities. These pictures will remain at the centre and/or may be sent home with the child. Throughout the year the staff at Adelfiha’s Childcare will be taking pictures of the children involved in many activities. These pictures will remain at the centre and/or may be sent home with the child. Yes, I give permission for my child to be photographed and his/her pictures to be posted in the daycare. No, I do not give permission for my child to be photographed and his/her pictures to be posted in the daycare.

Please type here for your signature

Emergency Medical treatment may be given to my child due to accident, illness, or other emergency. I hereby give permission that in case of any emergency, if I am not immediately available, emergency transportation to the nearest hospital will be arranged by a staff member through 911. Emergency Medical treatment may be given to my child due to accident, illness, or other emergency. I hereby give permission that in case of any emergency, if I am not immediately available, emergency transportation to the nearest hospital will be arranged by a staff member through 911. I understand the terms.

Please type for your signature

Bill Payer's Full Name (Mr./Ms./Mrs./)

Street Address

Apt.#

City

Province

Postal Code

Day Telephone #

Evening Telephone #

Email Address

Please type name here for signature

Date