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
Physician
Office #
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.
Birthdate*
Nickname
Sex MaleFemale
Yrs
Mos
Enrollment Date*
Withdrawal Date*
Mailing Address
Street Address
Email Address
Mother's Name
Cell #
Work #
Father's Name
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
Family Physician
Personal Health Number
Child Immunization YesNo
Rubella YesNo
General
Any Allergy/Reactions/Treatments
Illness or Medical Treatments
Is there anyone not permitted to pick up your child?
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*
Would you like some information about Preschool Subsidy for Fees? YesNo