registration

REGISTRATION FORM

Areas Marked With An * Must Be Filled Out - (Information is kept confidential)

Name of Child *

Date of Birth *

Name Child Responds To *

Sex of Child *

Male Female

Phone Number *

Street Address *

City *

Postal Code *

Mother's Name *

Occupation *

Employer *

Business Phone *

Cell Phone or Pager *

Father's Name *

Occupation *

Employer *

Business Phone *

Cell Phone or Pager *

Family Email Address *

Person(s) whom child lives with *

If there is a Custody Agreement, please give details *

Person(s) Authorized to pick up child from *

Authorization Pick Up List

(Alternative Responsible Relatives or Friends within the area)

Authorize Person #1 Name *

Authorize Person #1 Phone *

Authorize Person #1 Address *

Authorize Person #2 Name *

Authorize Person #2 Phone *

Authorize Person #2 Address *

Authorize Person #3 Name

Authorize Person #3 Phone

Authorize Person #3 Address

Authorize Person #4 Name

Authorize Person #4 Phone

Authorize Person #4 address

Other Children In The Household

Please Note: We Will Not Release Your Child To Anyone Who Is Not On The List

* Please let these people know they might be called in case of an emergency *

House Child #1 Name

House Child #1 Birthdate

House Child #1 Relationship

House Child #2 Name

House Child #2 Birthdate

House Child #2 Relationship

House Child #3 Name

House Child #3 Birthdate

House Child #3 Relationship

Languages Spoken In The Home *

Do you have any customs or religious beliefs of which you feel we should be aware? *

Child's Interests and Activities

What other type of group experiences has your child had? *

Does you child prefer to play (check all that apply) *

Alone With Playmates With Siblings With Adults

Does your child have imaginary playmates? *

Does your child have any pets? *

What are his/her favourite indoor activities? *

What are his/her favourite outdoor activities? *

Guidance and Behaviour

Would you judge your child to be: *

Easily Managed Fairly Easily Managed Difficult to Manage

Does your child: *

Have Any Fears Anger Easily Difficult to Manage Become Easily Discouraged

Any special words, songs, objects or actions which seem to help soothe and comfort your child? *

Are there any special circumstances in the family, which may be a factor in your child's present behaviour? *

Do you have any concerns about your child's present behaviour? *

Would you like your child to nap? *

Yes No

If so, what times? Usual Length? *

What does your child currently sleep in? *

Bed Crib

Are there any sleeping details that would be useful to us?

Is your child toilet trained? *

Yes Daytime Only In Process No

Any special instructions regarding toilet training?

Any additional comments that you feel will help us know your child better?

Health Information

Is your child immunized? *

Yes No

Please place a checkmark for all immunizations received to date *

2 Months *

DTaP-HBIPV-Hib Pneumococcal Meningococcal C Rotavirus

4 Months *

DTaP-HBIPV-Hib Pneumococcal Rotavirus

6 Months *

DTaP-HBIPV-Hib HEP A

12 Months *

HEP A

18 Months *

DTaP-HBIPV-Hib

Also, please state whether you have made a decision to NOT have your child immunized. This information is very important *

Child’s Personal Health Care No. *

Has your child had a vision test? *

Has your child had a hearing test? *

Past Illnesses (check all that apply) *

Does your child have any allergies? *

Yes No

Allergy #1 *

Allergy #1 Anaphylactic? *

Yes No

Allergy #2

Allergy #2 Anaphylactic? *

Yes No

Allergy #3

Allergy #3 Anaphylactic?

Yes No

Is your child on a special diet, or eat special foods? *

Yes No

Reason for special diet or foods? *

Does your child have speech difficulties? *

Yes No

Has your child been under a doctor’s care for any prolonged time? *

Yes No

Please Explain *

Family Doctor *

Doctor Phone Number *

Doctor Address *

Family Dentist*

Dentist Phone Number *

Dentist Address *

Parent Name *

Date Signed & Submitted *