Please complete this form. Registration Form For Child Care. Parent Email * Program Infant / Toddler Childcare Jr. Kindergarten School Age Care - Before & After School School Age Care - Before School School Age Care - After School Program Days * Monday Tuesday Wednesday Thursday Friday Facility Name * Playbox Childcare Centre Name Of Child * First Name Last Name Usual Name Of Child If different. Personal Information Child's Date Of Birth * MM DD YYYY Gender * Male Female Starting Date * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Telephone * (###) ### #### 1. Parent Or Guardian * First Name Last Name 1. Address * Address 1 Address 2 City State/Province Zip/Postal Code Country 1. Work Address * Address 1 Address 2 City State/Province Zip/Postal Code Country 1. Telephone * (###) ### #### 1. Cell Phone * (###) ### #### 1. Hours At This Location * 2. Parent Or Guardian First Name Last Name 2. Address Address 1 Address 2 City State/Province Zip/Postal Code Country 2. Work Address Address 1 Address 2 City State/Province Zip/Postal Code Country 2. Telephone (###) ### #### Cell Phone (###) ### #### 2. Hours At This Location Emergency Health Information Care Card Number * Family Doctor * Clinic Name * Doctor / Clinic Telephone * (###) ### #### Consent For Emergency Care * I authorize the staff at the child care centre to call a medical practitioner or ambulance / transport child to emergency medical care, in the case of accident or illness of my child(ren), if the parent cannot immediately be reached. Yes No Alternate Person(s) Authorized To Pick Up Child Other than parent / guardian listed above, include emergency pickup. Name - Alternate 1 First Name Last Name Relationship - Alternate 1 Telephone - Alternate 1 (###) ### #### Permission for Alternate 1 Authorized to Pickup Authorized to Call in an Emergency Name - Alternate 2 First Name Last Name Relationship - Alternate 2 Telephone - Alternate 2 (###) ### #### Permission for Alternate 2 Authorized to Pickup Authorized to Call in an Emergency Person(s) Who Are Not Permitted Access To My Child 1. Name - Of Not Permitted First Name Last Name 1. Relationship - Of Not Permitted 1. Telephone - Of Not Permitted (###) ### #### 2. Name - Of Not Permitted First Name Last Name 2. Relationship - Of Not Permitted 2. Telephone - Of Not Permitted (###) ### #### Custody Or Other Legal Orders * If yes, supply a copy of the order to the facility Manager / Licensee Yes No Child's Immunization Status * Yes No Not Immunized Comments Health Information Attach a separate sheet, if necessary. Regular Medication(s) And Reasons For Please list. Allergies And Treatment Of Please list. Injury(s) Illness(es) Or Operations Your Child Has Had And Include Date(s) 1. Please describe any concern(s) / issues regarding your child's health. Seizures, asthma, vision, hearing, etc. 2. Please describe any concerns you may have regarding your child's development. i.e. behaviour, vision, hearing, speech, language, mobility, etc. 3. Describe any specific care instruction regarding 1) and/or 2) above. Other Health Care Professionals Involved In Your Child's Life e.g. occupational therapist / physical therapist Any Other Information I should Know Name Of Parent Or Guardian Providing Information * First Name Last Name I, named above as Parent or Guardian here by acknowledge all the information provided above is correct. * I Agree Thank you! Optional: Help Us Get To Know Your Child Better. Additional Information About Your Child Full Name Of Child * First Name Last Name Group Experiences What is/are your child's favourite toy(s) / activities? Has your child had previous play group experiences? Yes No If yes, how did he/she adapt? How does your child behave toward other children? e.g. seeks others out, feels shy Emotional How does your child react when left with unfamiliar people and/or in unfamiliar situations? Does your child have any particular fears? Please describe. What suggestions do you have that would help staff make your child's transition into this program easier? Family And General Household Information Please list the names of the significant people in your child's life. e.g. siblings, grandparents, etc. Please describe the guidance and discipline method used at home. Primary language spoken in the home. Other languages Name of english speaking person If needed. Telephone Eating And Nutrition List your child's favourite food. List any disliked food. Please describe any particular eating patterns. Are there any religious or ethnic observations related to food? Sleeping Nap Time Hour Minute Second AM PM How long to settle for nap time? Time Of Waking - Nap Time Hour Minute Second AM PM Bedtime Hour Minute Second AM PM How long to settle for bedtime? Time of Waking - Bedtime Hour Minute Second AM PM Does your child take a favourite comforter to bed? e.g. blanket or toy Yes No If yes, describe and tell us if it is "named" What is your child's mood upon wakening? Toileting Is your child toilet trained? Yes No Partially Please indicate your child's frequency or patterns for bowel movements. Describe assistance needed for toileting. What "special" word does your child use for urination? What "special" word does your child use for bowel movements? Thank you!
