Preschool 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 - Emergency Consent 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 Step 7 - 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 8 - Submit Your Application Privacy Policy | Terms of Use Privacy Policy & Terms of Use Privacy Policy & Terms of Use By clicking the "submit" button, you agree to ACA's Privacy Policy & Terms of Use Submit
