Alberta Rose day Care & OSC

Date of Enrollment *

Health Card Number *

Child's Full Name (First, Middle & Last) *

Child's Date of Birth *

School Attended (if applicable)

Hours of Care Required *

Days *

Reason For Care *

Medical Emergency Authorization:
In the event of a medical emergency and I/We cannot be reached, I/We hereby authorize Alberta Rose Daycare & OSC to obtain medical treatment for my child from my doctor or any other physician selected by the center.

Full Name & Relation *

Address *

Postal Code *

Home Phone *

Cell Phone *

Work Phone

Email *

Full Name & Relation

Address

Postal Code

Home Phone

Cell Phone

Work Phone

Does your child have any chronic health problems (Asthma, Allergies, Diabetes, Convulsions, etc.)? *

Yes No

Does your child take medication regularly? If yes, please list:

Does your child have any special dietary restrictions? *

How does your child react to minor injuries (bumps, scrapes)? What comforts him/her? *

Information for Children Under 12 Months (Complete only if applicable)

Please describe your child's daily routine

Specific dislikes or fears?

Likes or special activities that your child enjoys?

Specific feeding routine? (Formula or Breast Milk, # and times of feedings)

Specific sleeping routine? (# and approximate times of napping, rocked to fall asleep, etc.)

Please initial beside each consent you agree to. Mark "No" for any you do not consent to.

Parent or Guardian Signature

Supervisor / Director Signature

Registration Form

Child Enrollment Form

Child Information

Medical Information

Parent / Guardian Information

Individuals Authorized to Pick Up the Child

Emergency Contacts

Health Information

Child Dietary & Behavioral Information

Consents

Signatures

opening hours

closed

Our Program

Our Map