Enrolment/Registration

Child's Information

Child´s Name

Date of birth

Home Address

Gender

Female Male

City/Province/ Postal Code

Home Phone Number

Child's Health Care Number:

Doctor's Name

Health Information

Does your child have any allergy, sensitivities or special needs?

Yes No

If yes, please explain below:

Does the child have any medical conditions and needs (eg epilepsy, diabetes, anaphylaxis, asthma, etc.) which are relevant to the centre?

Yes No

If yes, please explain below:

Is your child's immunization up-to date?

Yes No

If not, Please note: If an outbreak of vaccine preventable illness occurs, and your child has not received medical immunisation, your child will not be able to attend the centre during this time.

If Yes, please provide the details by: Attaching a copy of the immunisation record from the Child Health Record Book:

Is there is anything else that the centre should know about your child (eg excessive fears, fear of loud noises etc.)

Add another child

Child's Information

Child´s Name

Date of birth

Home Address

Gender

Female Male

City/Province/ Postal Code

Home Phone Number

Child's Health Care Number:

Doctor's Name

Health Information

Does your child have any allergy, sensitivities or special needs?

Yes No

If yes, please explain below:

Does the child have any medical conditions and needs (eg epilepsy, diabetes, anaphylaxis, asthma, etc.) which are relevant to the centre?

Yes No

If yes, please explain below:

Is your child's immunization up-to date?

Yes No

If not, Please note: If an outbreak of vaccine preventable illness occurs, and your child has not received medical immunisation, your child will not be able to attend the centre during this time.

If Yes, please provide the details by: Attaching a copy of the immunisation record from the Child Health Record Book:

Is there is anything else that the centre should know about your child (eg excessive fears, fear of loud noises etc.)

Add another child

Child's Information

Child´s Name

Date of birth

Home Address

Gender

Female Male

City/Province/ Postal Code

Home Phone Number

Child's Health Care Number:

Doctor's Name

Health Information

Does your child have any allergy, sensitivities or special needs?

Yes No

If yes, please explain below:

Does the child have any medical conditions and needs (eg epilepsy, diabetes, anaphylaxis, asthma, etc.) which are relevant to the centre?

Yes No

If yes, please explain below:

Is your child's immunization up-to date?

Yes No

If not, Please note: If an outbreak of vaccine preventable illness occurs, and your child has not received medical immunisation, your child will not be able to attend the centre during this time.

If Yes, please provide the details by: Attaching a copy of the immunisation record from the Child Health Record Book:

Is there is anything else that the centre should know about your child (eg excessive fears, fear of loud noises etc.)

Add another child

Child's Information

Child´s Name

Date of birth

Home Address

Gender

Female Male

City/Province/ Postal Code

Home Phone Number

Child's Health Care Number:

Doctor's Name

Health Information

Does your child have any allergy, sensitivities or special needs?

Yes No

If yes, please explain below:

Does the child have any medical conditions and needs (eg epilepsy, diabetes, anaphylaxis, asthma, etc.) which are relevant to the centre?

Yes No

If yes, please explain below:

Is your child's immunization up-to date?

Yes No

If not, Please note: If an outbreak of vaccine preventable illness occurs, and your child has not received medical immunisation, your child will not be able to attend the centre during this time.

If Yes, please provide the details by: Attaching a copy of the immunisation record from the Child Health Record Book:

Is there is anything else that the centre should know about your child (eg excessive fears, fear of loud noises etc.)

Add another child

Child's Information

Child´s Name

Date of birth

Home Address

Gender

Female Male

City/Province/ Postal Code

Home Phone Number

Child's Health Care Number:

Doctor's Name

Health Information

Does your child have any allergy, sensitivities or special needs?

Yes No

If yes, please explain below:

Does the child have any medical conditions and needs (eg epilepsy, diabetes, anaphylaxis, asthma, etc.) which are relevant to the centre?

Yes No

If yes, please explain below:

Is your child's immunization up-to date?

Yes No

If not, Please note: If an outbreak of vaccine preventable illness occurs, and your child has not received medical immunisation, your child will not be able to attend the centre during this time.

If Yes, please provide the details by: Attaching a copy of the immunisation record from the Child Health Record Book:

Is there is anything else that the centre should know about your child (eg excessive fears, fear of loud noises etc.)

Parent's Or Guardians Information

Father's Name:

Mother's Name:

Home Address/City/ Province/Postal Code:

Home Phone Number:

e-mail address

Work Address/City/ Province/Postal Code:

Work Phone Number:

Emergency Contacts – must be other than parents or guardians

There may be times when your child has an accident, injury, trauma or illness and the parents or guardians cannot be contacted or are unable to collect your child due to other commitments. To deal with these situations, the centre must be able to notify one of the following people who are authorised and available to collect and care for your child.

An Emergency contact is an acknowledged person who, with the parents / guardian’s authorisation, is allowed to give permission for the following:

Authorise the taking of your child outside the service by a staff member of the service.
Consent to the medical treatment of your child.
Request or permit the administration of medication to your child.
Collect your child if necessary.

In case of an emergency, I give permission for any of the following individuals to be contacted and my child may be released to any of them.

Emergency Contact Name #1:

Emergency Contact Name #2:

Home Address/City/ Province/Postal Code:

Home and work Phone Number:

Relationship:

Other than you, who else has permission to pick up your child?

This list may be added to or changed throughout the year. Please note:

Children will not be released to anyone who is not authorized in writing by the parent / legal guardian.
The people on this list may be required to produce photo identification such as a drivers licence.
People on this list must be aged 18 years and older, and must live in surrounding areas for immediate pickup if required.
NO TELEPHONE CALLS are acceptable to change authority for pick-up authorization (MUST BE IN WRITING).
Little Children Day Homes reserves the right to refuse ANYONE picking up a child who does not appear to be in a responsible condition.

Full Name #1:

Full Name #2:

Home Address/City/ Province/Postal Code:

Home and work Phone Number:

Relationship:

Who does not have permission to pick up your child? If applicable (A copy of supporting court document must be on file)

Are there any court orders relating to the powers and responsibilities of the parents in relation to your child or access to your child?

Yes No

If Yes - Please bring the original court order/s for Educators to see and copy to attach to this enrolment form:

Full Name:

Reason:

Day Activities

What kinds of activities would you like your child to participate in?

What are your child's favorite toy or activities?

Does your child require a nap time?

Eating

Does your child drink from a bottle?

Yes No

What are some of your child's favorite foods?