H515 Child Care Facilities Registration Form printable pdf download

H515 Child Care Facilities Registration Form

H515-94/1

CHILD CARE FACILITIES REGISTRATION FORM

CHILD’S STARTING DATE:

DATE OF BIRTH:

SEX:

_______/_______/_______

M___F___

YEAR

MONTH

DATE

YEAR

MONTH

DATE

NAME OF CHILD:____________________________________________________________

(SURNAME)

(GIVEN NAME)

(ALSO KNOWN AS)

NAME CHILD RESPONDS TO: __________________________________________________

ADDRESS:__________________________________________________________________

POSTAL CODE:_____________________________________ PHONE:__________________

PERSON(S) WITH WHOM CHILD LIVES (ADULTS & CHILDREN):______________________

__________________________________________________________________________

CHILD’S FIRST LANGUAGE:____________________ SECOND LANGUAGE: ______________

PARENT(S)/GUARDIAN(S):

NAME:_________________________________________ HOME PHONE: ________________

WORK PHONE:________________ LOCAL: ____________ DAY/HOURS OF WORK: _________

NAME:_________________________________________ HOME PHONE: ________________

WORK PHONE:________________ LOCAL: ____________ DAY/HOURS OF WORK: _________

PERSON(S) AUTHORIZED TO PICK UP CHILD AND/OR BE CONTACTED IN CASE OF

EMERGENCY (INCLUDE MOTHER/FATHER/GUARDIAN):

NAME:_________________________________RELATIONSHIP TO CHILD:______________

HOME PHONE:___________________________WORK PHONE:_________________________

NAME:_________________________________RELATIONSHIP TO CHILD:______________

HOME PHONE:___________________________WORK PHONE:_________________________

NAME:_________________________________RELATIONSHIP TO CHILD:______________

HOME PHONE:___________________________WORK PHONE:_________________________

NAME:_________________________________RELATIONSHIP TO CHILD:______________

HOME PHONE:___________________________WORK PHONE:_________________________

IF APPROPRIATE, ENGLISH SPEAKING CONTACT:

NAME:_________________________________PHONE:______________________________

IF THERE IS A CUSTODY AGREEMENT, PLEASE GIVE DETAILS AND ATTACH COPY:

__________________________________________________________________________

H515 Child Care Facilities Registration Form