Registration form for child care

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Registration Form For Child Care
Facility Name
Full Name of Child
Usual Name of Child (If Different)
Personal Information
Child's Date of Birth
Starting Date
Gender
- Male
- Female
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Parent or Guardian
Parent or Guardian
Work Address Alternate Location (If Different from Above)
Street Address Address Line 2 City State / Province / Region
Work Address Alternate Location (If Different from Above)
Street Address Address Line 2 City State / Province / Region
Phone (Include Local)
Phone (Include Local)
Email:
Email:
Hours At This Location
Hours At This Location
Emergency Health Information
Care Card Number
Family Doctor/Clinic Name
Family Dentist/Clinic Name
Phone
Phone
Address
Address
Consent For Emergency Care
I authorize the staff at the Child Care Centre to call a medical practitioner or ambulance in the case of an accident or illness of my Child the parent cannot immediately reached.
Signature of Parent/Guardian
Date
Manager of Facility
Person(s) Authorized to Pick Up Child(ren)
(Other than parent/guardian listed above)
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone

Person(s) NOT Authorized to Pick Up Child(ren)
Name
Relationship
Phone
Name
Relationship
Phone
Custody Agreement
Select Custody Agreement
- Yes
- No
If Yes, Supply a Copy of Custody order to the facility Manager/Licensee.
Alternate Person(s) To Call and Pick Up Child In Case Of Emergency
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone
Child's Immunization Status
(Please Record Dates (Year/Month/Day) or attach copy of immunization )
Is Your Child Up To Date On Immunised Status?
- Yes
- No
- Not Immunised
Or Attach file
(Attach Copy of Immunisation)
IF YES, PLEASE FILL UP BELOW WITH DATE LIST
Diphtheria
Pertussis
Tetanus
Polio
MMR
HIS
Comments:

Health Information
Please 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 And Include Date(s):
a) Please describe any concern/issues regarding your child's health
(Seizures, Asthma, Vision, Hearing, etc.)
b) Please describe any concerns you may have regarding your Child's development
(ie. Behaviour, Vision, Speech, Languages, Mobility, etc)
c) Describe any specific care instruction regarding a) or b)
Other Health care professional involved in your Child's life (i.e. Occupational, Therapist/Physical,)
( ie. Occupational, Therapist/ Physical Therapist, Therapist)
Group Experience
What is /are your child's favourite toy(s) activities?
Has your child had play group experience?
- Yes
- No
If yes, How did he/she adapt?
How does your Child behave toward other children (ie. Seeks out, Feels Shy)
Family and General Household Information
Please list the names of significant people in your child's life

(ie. Sibling, Grandparents, etc.)
Please describe the guidance and discipline methods at home;
Primary Languages Spoken in the home
Other Languages

Away Day Consent From
From time to time , we take the children out from the centre for an Away Day. Sometimes we talk the children to the local school playground or park. At other time we transport the children in the van to the library or a school that is not within walking distance. Please sign the consent forms below so that your child may participate in these activities.If your child cannot go on a specific day, Please let us know in advance.
I hereby give my permission for my child
to be driven in the school van to the library or a school in the Walnut Grove area. I understand that my child will be supervised at all times by the staff of Bright Angels Children's Centre while on these walks.
I hereby give my permission for my child
to go on walks with the staff of Bright Angels Children's Centre to a nearby school or park. I understand that my child will be supervised at all times by the staff of Bright Angels Children's Centre while on these walks.
Parent/Guardian's Name:(Please print)
Signature
Date

Emotional
How does Your Child React when Left With Unfamiliar People and/or 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 Programme Easier?
Family and General Household Information
Name Of English Speaking Person(s) (If needed)
Phone:
Any Other Comments
Signature of Parent or Guardian Providing Information
Signature
Print Name:
Date
Note: This Information May Be Reviewed by Fraser Authority Licencing Staff As Per Legislation.
Signature of Parent or Guardian Providing Information
Facility Use Only
Staff Person Reviewing Families Documents.
Signature
Print Name:
Date
Child's Withdrawal Date
Reason For Withdrawals:
Additional Child History

From time to time, we take the children out from the center for an Away Day, Sometimes we walk the children to the local school playground or park. At other times we transport the children in the van to the library or a school that is not within distance, Please sign the consent forms below so that your child may participate in these activities. If your child cannot go on a specific go on a specific day.
please let us know in advance
I hereby give permission for my child
to go on walks with the staff of Bright Angels Children's Centre to a nearby school or park. I understand that my child will be supervised at all times by the staff of the Bright Angels Children's Centre while on these walks.
I hereby give permission for my child
to be driven in the school van to the library or a school in the Walnut Grove area. I understand that my child will be supervised at all times by the staff of the Bright Angels Children's Center while on these trips.
Parent/Guardian's Name:
Signature
Date

Registration Form For Child Care