Childcare Registration Form printable pdf download

Childcare Registration Form

CHILD CARE REGISTRATION FORM

Unifor Family Education Centre

Port Elgin, Ontario

CHILD INFORMATION

Child's Name:

Full Name

Address:

Street & Number

City

Province

Postal Code

Gender: _____________.

Birthday:

(day / month /year)

Principal Home Language:

Name(s) of people to whom the child may be released:

PARENT INFORMATION

Name of Parent/Guardian:

Local # (i.e. L. 222):

Address

(If different than above)

Street & Number

City/Town

Province

Postal Code

Home Phone:

Work Phone:

Cell Phone: ________________________________________.

E-Mail Address: __________________________________.

MEDICAL INFORMATION

Child's Health Card Number and Initials:

Is your child currently under a Doctor's care? (If "yes", please describe):

Yes:

No:

Is your child receiving any medication on an ongoing basis? If yes describe what medication is for and times that it is to

be taken:

Yes:

No:

Does your child have any dietary restrictions? If yes please list/explain:

Yes: __________. No: _________.

Does your child suffer from any medical conditions such as allergies, asthma and disease? If "yes", please list and explain

in detail the medical condition:

Childcare Registration Form