Registration Form

Child Information

Date of Enrollment:

Child’s First Name, Middle Name & Last Name:

Child’s Date of Birth:

School Attended (if applicable):

Hours of Care Required:

Reason For Care:

Child Resides With: Please Select Mother Father Both Guardian

Custody Agreement: Please Select Yes No

If Yes, provide details of the agreement:

Others in the household and relationship:

Medical Information

Immunization Records current and up to date: Please Select Yes No

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.

Parent/Guardian Information

Parent/Guardian 1

Parent/Guardian 2

Child Behavioral & Dietary Information

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

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)

Consents

I authorize Alberta Rose Day Care & OSC employees to accompany my child on community walks within a 2 km radius of the centre. I understand that any other excursions will require a separate signed consent.

I consent to Alberta Rose Day care & OSC Centre taking photos and videos of my child for use in displays within the centre.

Individuals Authorized to Pick Up the Child

Add More

Emergency Contacts (all information MUST be completed)

Add More

Health Information

Health Card Number

Does your child have any special needs? Please Select Yes No

Medical Information

Does your child have any chronic health problems such as Asthma, Allergies, Diabetes, Convulsions, etc.? Please Select Yes No

If yes, the Emergency Medication Plan must be completed

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

Add Medication