Parent Registration

NAME OF CHILD:__________________________________ M F

LAST NAME FIRST NAME

DATE OF BIRTH:_______________________________

DAY/MONTH/YEAR

General Health:________Any known allergies, health or medical problems? Circle YES/NO

If yes, please describe:________________________________________________________________

Parent/Guardian:___________________ Parent/Guardian:______________________

Address:________________________ Address:____________________________

_______________________________ ___________________________________

Postal Code:_____________________ Postal Code:__________________________

Home Phone: ( )__________________ Home Phone: ( )_______________________

Cell/Pager #:_____________________ Cell/Pager #:_________________________

Company:_______________________ Company:____________________________

Company Address:_________________ Company Address:_____________________

_______________________________ ___________________________________

Occupation:______________________ Occupation:__________________________

Business Phone:___________________ Business Phone:_______________________

Email Address:____________________ Email Address:________________________

Custody arrangements (if applicable):_______________________________________

Language(s) spoken at home:___________________Date Day Care Required___________

Pyshician’s Name:____________________ Address:___________________________

Phone: ( )______________________ Health Card#:__________________________

Persons to contact in emergency if parents cannot be reached, and to whom child may be released:

Name:_______________Phone:( )__________Relationship:____________________

Name:_______________Phone:( )__________Relationship:____________________

Hours of work:______________________ Days of Work:_______________________

I will need day care for the following days and hours:_____________________________

Closest intersection to work:______________________________________________

Closest intersection to home:_____________________________________________

Child’s School if applicable (Name and Location):_______________________________

Does your child need pick up and drop off at school: Circle YES/NO

Provider locations (furthest acceptable boundaries):_____________________________
___________________________________________________________________

(1) What qualities are you looking for in a provider?:____________________________

__________________________________________________________________

__________________________________________________________________

(2) What types of activities does your child enjoy? And what would you like your child to be occupied with while in care?:_____________________________________________________
__________________________________________________________________
___________________________________________________________________

(3) Tell us a little bit about your child?:______________________________________
__________________________________________________________________
___________________________________________________________________
(4) Before placing your child, are there any specific concerns or circumstances we should be made aware of?:____________________________________________________________
__________________________________________________________________
___________________________________________________________________

Do you or your spouse smoke?_______Do you have pets?______What type?_________

Please outline any additional comments or requirements regarding day care for your child:____

___________________________________________________________________
____________________________________________________________________

How did you hear about Kiddie Kare? (please circle any that apply): ‘word of mouth’, Yellow Pages, News Paper, other (please specify)__________________________________________

______________________________ __________________________

Signature of Parent/Guardian Date

This form must be returned before interviews can be scheduled. Please enclose a non-refundable $45.00 cheque for registration along with your form. If you are faxing in your application, please mail your cheque with your original application. Your signature means that you understand that you cannot make private arrangements during interviews with potential caregivers. Fax 905-822-4684

DATE APPLICATION RECEIVED:___________________ ACKNOWLEDGED

DATE OF INTERVIEW:___________________________

START DATE:_________________________________

NAME OF PROVIDER:___________________________

NAME OF WORKER:____________________________

REASON FOR DISCHARGE;_______________________

DATE OF WITHDRAWAL:__________________________

MEDICAL SURNAME OF CHILD:__________________________________

FORM FIRST NAME:__________________________________________

ADDRESS:____________________________________________

DATE OF BIRTH:_______________________________________

HEALTH CARD #:______________________________________

NAME OF DOCTOR:_____________________________________

PHONE #:____________________________________________

ADDRESS:____________________________________________

CHICKEN POX GERMAN MEASLES

MEASLES SCARLET FEVER

RUBELLA WHOOPING COUGH

LIST ANY SERIOUS ILLNESSES, DISABILITIES, OPERATIONS:_______________
_____________________________________________________________

LIST ANY ALLERGIES TO FOOD OR MEDICINES:________________________

_____________________________________________________________

ANY PHYSICAL DISABILITY OR ABNORMAL CONDITION (HEALTH concern) WHICH WOULD RESTRICT ACTIVITY:

_____________________________________________________________________
____________________________________________________________________
___________________________________________________________________-

IF ACTIVITY NEEDS TO BE CONTROLLED, WHAT IS THE DURATION OF RESTRICTIONS:_____________________________________________________

____________________________________________________________________
____________________________________________________________________
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IN THE EVENT OF A HIGH FEVER, TEMPERA OR TYLENOL MAY BE ADMINISTERED TO THE ABOVE NAMED CHILD, UPON VERBAL PERMISSION FROM THE PARENT

YES NO

_________________________________ ______________________

SIGNATURE OF PARENT DATE

I GIVE PERMISSION FOR THE PROVIDER TO APPLY SUN SCREEN (WHICH I WILL PROVIDE) TO MY CHILD, AS NECESSARY.

_________________________________ _______________________

I GIVE PERMISSION FOR THE PROVIDER TO APPLY MEDICATED CREAM SUCH AS ______________________________ (WHICH I WILL PROVIDE) TO MY CHILD AS NECESSARY.

___________________________________ ______________________

SIGNATURE OF PARENT DATE