Child's Name*

Child's Birthdate*

Child's Eye Colour*

Child's Hair Colour*

Child's Skin Colour/Ethnicity*

Parent's Signature*

Date*

Attach Photo of Child

Child's Name

D.O.B

Gender

Address

Postal Code

Health Care #

Parent(s)

Home #

Work/school #

Emergency Contacts

Home #

Work/school #

Physician

Office #

Address

Allergies

Health Problems

In case of accident, injury or illness, i authorize to contact a physician and/or ambulance and to seek medical attention for my child. I also consent for my child to be transported by ambulance or in a staff vehicle to obtain medical attention.

Parent's Signature*

Date*

Child's Name*

Birthdate*

Nickname

Sex MaleFemale

Age

Yrs

Mos

Enrollment Date*

Withdrawal Date*

Mailing Address

Street Address

Email Address

Mother's Name

Home #

Cell #

Work #

Father's Name

Home #

Cell #

Work #

Parent's Occupation

Languages spoken at home

Person to call in case of accident (other than parents listed above)

Phone #

Persons authorised to pick up child from facility (other than parent/guardian)

Name

Relationship to child

Phone #

Name

Relationship to child

Phone #

Name

Relationship to child

Phone #

Family Physician

Phone #

Personal Health Number

Child Immunization YesNo

Rubella YesNo

Health

General

Allergies

Any Allergy/Reactions/Treatments

Illness or Medical Treatments

Is there anyone not permitted to pick up your child?

Family

Adults at home

Siblings

Pets

Child's previous experience in a playgroup?

Child's special likes

What do you hope your child will gain from preschool?

If there is a custody agreement, please give details. A copy of the custody order must be left with the preschool staff.

Signature*

Date*

Would you like some information about Preschool Subsidy for Fees? YesNo