Preschool Re-enrollment Registration Form

Step 1 - Student Information

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

Step 2 - Parent Information

Mother/Guardian Name

Address

Occupation

Employer/School

Employer/School Address

Marital Status

Home Phone

Work/School Phone

Cell Phone

Email Address

Step 3 - Parent Information

Father/Guardian

Address

Occupation

Employer/School

Employer/School Address

Marital Status

Home Phone

Work/School Phone

Cell Phone

Email Address

Step 4 - Doctor Information

Child's Doctor

Street

City

Phone

Province

Postal Code

Special diet:

Allergies:

Medication:

History of communicable diseases:

Step 5 - Pick up information

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

Phone Number

Relation to the child

Does the above person have permission to pick up the child? Does the above person have permission to pick up the child? 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

Step 6 - Billing Information

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

Step 10 - Submit Your Application Privacy Policy | Terms of Use

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