On Site Child Care Registration Form Cupe Ontario

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ON SITE CHILD CARE REGISTRATION
This form is to be completed for delegates who intend to bring their child(ren) (infant to 9 years old) to
Convention. Please complete a separate form for each child to be registered. (Additional copies may
be photocopied).
Dates of Child Care required for Convention: (check all applicable dates):
th
th
th
th
th
May 24
May 25
May 26
May 27
May 28
Child Information: (please print)
Name of Child: ______________________________________
Age of Child: _____________
Medical Issues, Allergies or Special Care: ____________________________________________
Languages spoken:
English
French
Other (please specify): __________________
Consent (please print):
I, __________________________________ (parent/guardian) hereby give permission for my child
registered above to participate in various recreational and leisure activities offered by the trained staff
of the On-Site Child Care during the period of the above-named conference.
Release of Responsibility (please print):
I, ___________________________________ (parent/guardian) hereby release CUPE Ontario from
any and all claims for damages to the safety or health of my child registered above, howsoever
caused, while participating in any activities of the On-Site Child Care during the period of the above-
named conference.
Signature of Parent / Guardian: ________________________________ Date: _______________
Parent / Guardian Contact Information: (please print)
Address: ______________________________________________________Local No. __________
City: ________________________________________ Postal Code: ________________________
E-mail: __________________________________________________________________________
Phone Number: Home (
) ______________________ Work: (
) _____________________
Cell Phone: (
) ______________________
Signature of Witness: _________________________________________ Date: _______________
Name of Witness (please print): _______________________________
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