Child Care Registration Form Ymca

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YMCA of Central East Ontario
Belleville Branch
Child Care Registration
Date Received
Date Revised
* A Non Refundable $35.00 registration fee is required for all new registrations
Preferred Start Date
Email Address
Child's Name Last
First
Initials
Nickname(s)
DOB YYYYMMDD
Address
Postal Code
Age
School Attending

Program
Toddler
Pre-School
Kids Club
Component
Morning
Afternoon
Full Day

Monday
Tuesday
Wednesday
Thursday
Friday
Days Required
** A Minimum of 2 days per week is required to hold your space**
Mother's / Guardian's Name and Address
Home Telephone Number
Cell Number
Place of Employment and Address
Work Number
Father's / Guardian's Name and Address
Home Telephone Number
Cell Number
Cell Number
Place of Employment and Address
Work Number
Emergency Contact Name and Address
Home Telephone Number
Cell Number
Place of Employment and Address
Work Number
Authorized persons who may pick up child
2
3
1.
4
5
6
Medical Information
Previous communicable diseases, illnesses or injuries
Medical conditions or known allergies
Record of immunization required for full day care spaces
Special Medications / Diets

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