Registration Form

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Child Information
Child's Full Name: Name child responds to:
Birth date: Starting Date :
Address:
Phone Number:
Child's first language: Child's second language:
Person(s) with whom child lives:
Parent/Guardian Information
Mother's Name:
Address:
Home Phone Number:
Place of work: Work Phone Number:
Father's Name:
Address:
Home Phone Number:
Place of work: Work Phone Number:
 
Emergency Contacts
Name: Relationship: Phone No.:
Name: Relationship: Phone No.:
Name: Relationship: Phone No.:
Name: Relationship: Phone No.:
Person(s) Authorized to Pick up Child
Name: Relationship: Phone No.:
Name: Relationship: Phone No.:
Name: Relationship: Phone No.:
Name: Relationship: Phone No.:
 
Custody Agreement Details (if any). Please provide copies of any official documents.
 
Child History
What are your child's...
Favorite Activities:
Food Dislikes:
Sleeping Patterns:
Toileting Practices:
Religious or Cultural Beliefs:
Is your child subject to...
Ear/Nose/Throat Infections: Urinary Tract Infections: Bleeding Noses:
Skin Problems: Seizures: Allergies:
Other Medical Conditions: Emotional Problems: Learning Disabilities:
What are your child's...
Previous Experiences away from home: Reactions to Separation: Significant Events in the Past Year:
Other children living at home
Name: Age:
Name: Age:
Name: Age:
Name: Age:
 
Has your child previously attended Daycare/Preschool?
Yes    NoName of facility:  
Days of attendance:  
Were there any problems:  
 
Immunization History
Please attach a copy of all immunization records
If you have chosen not to immunize please sign here:  
 
Emergency Health Information
Doctor: Phone No.: Address:
Dentist: Phone No.: Address:
Other: Phone No.: Address:
Care Card / Personal Health Number:
 
Emergency Consent
It is the policy of Kiddie Kollege to notify a parent when a child is ill or needs medical attention. Occasionally, we cannot contact parents, and we need to get immediate help for the child. Our procedure is to take the child to the nearest emergency service. Please sign below so that we can take appropriate action on Behalf of your child.

I hereby give my consent for my child, , when ill, to be taken to the nearest emergency centre by ambulance when I cannot be contacted. A staff member will accompany my child. Kiddie Kollege is no responsible for any medical expenses, including the cost of ambulance.
Signature of Parent/Guardian: Print Name: Date:
Work Phone Number: Home Phone Number: