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Child Information
Full Legal Name*
First Last
Preferred Name
Date of Birth*
MM slash DD slash YYYY
Age (years, months)*
Home Address*
Street Address City Postal Code
Language(s) Spoken at Home*
Other children in the family enrolled in the centre
list of names, if applicable
Program Selected*
- Infant (6-18 months)
- Toddler (18 months-2.6years)
- Preschool (2 ½ -4 years)
- Kindergarten (4-6 years)
*3 days programs are run M/W/F *2 day programs are run TH/TH

Parent Information
Parent's Full Legal Name*
First Last
Preferred Name
Relationship to Child*
Email Address*
Primary Phone Number*
Alternate Phone Number
Home Address (if different than child)
Street Address City Province Postal Code
Parent Occupation
Work Name & Address
Parent's Full Legal Name*
First Last
Preferred Name
Relationship to Child*
Email Address*
Primary Phone Number*
Alternate Phone Number
Home Address (if different than child)
Street Address City Province Postal Code
Parent Occupation
Work Name & Address
Custody Arrangements
Are there custody arrangements pertaining to legal right of access to your child?*
- Yes
- No
If YES, please provide a copy of the appropriate legal documents (e.g.) court order
Names of custodial parent(s)*
Name(s) of individuals prohibited from accessing/picking up your child*

Emergency Contacts
Full Legal Name*
First Last
Preferred Name
Relationship to Child*
Primary Phone Number*
Alternate Phone Number
Home Address*
Street Address City Postal Code
Is this person authorized to pick up your child?*
- Yes
- No
Full Legal Name
First Last
Preferred Name
Primary Phone Number
Alternate Phone Number
Home Address
Street Address City Postal Code
Is this person authorized to pick up your child?
- Yes
- No
Full Legal Name
First Last
Preferred Name
Primary Phone Number
Alternate Phone Number
Home Address
Street Address City Postal Code
Is this person authorized to pick up your child?
- Yes
- No

Medical Information
Additional Emergency Information
Please provide any special medical or additional information about your child that could be helpful in an emergency (e.g., medical conditions, skin conditions, vision/hearing difficulties)
Health Information
If your child has a history of communicable disease (e.g. chicken pox, measles) please list them below
Does your child have any medical needs that requires additional support? (e.g. Diabetes)
- Yes
- No
If yes, and individualized plan for children with medical needs must be developed between the parent and the school prior the child’s first day.
Immunization Record

An updated copy of your child’s immunization record must be provided to the school prior to your child’s start date.
Family Doctor Information
Doctor/Physician*
First Last
Address*
Street Address City Postal Code
Phone Number*
Allergy Information
Does your child have a life threatening allergy? (e.g. anaphylactic to peanuts or bee strings)*
- Yes
- No
If yes, an individual plan for an anaphylactic allergy that includes emergency procedures must be developed between the parent and the school prior to child’s start date.
Does your child have any allergies that are non-life threatening? (food or other substances e.g. latex)*
- Yes
- No
If yes, please provide relevant details, including what your child is allergic to, symptoms of reaction and treatment required:*
*** For Food Allergies and Restrictions please see Allery Form***
Sleep Arrangements
Does your child have any special sleep requirements?*
- Yes
- No
If yes, please provide relevant details:*

Child Information

Parent Information

Custody Arrangements

Emergency Contacts

Medical Information

Health Information

Immunization Record

Family Doctor Information

Allergy Information

Sleep Arrangements

Additional Information

Address

Phone

Email

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