Childcare Registration Form (Page 2 of 2) in pdf

Childcare Registration Form Page 2

Does your child have any special needs such as but not limited to ADD, ADHD, Autism, Aspbergers Syndrome, Cerebral

Palsy? If “yes”, please list and explain in detail the special need:

Does your child have any behavioural issues/concerns that we need to be aware of in order to maintain his/her safety

and the safety of the other children? If “yes”, please list and explain in detain the behavioural issues/concerns:

Is your child physically able to take part in all program activities?

Yes:

No:

If no, please list restrictions:

CONSENTS

Do you grant permission for your son/daughter/ward to participate on short supervised walks or excursions within a 2

km. radius from Unifor Child Care facility?

Yes:

No:

In the case of a medical emergency, every effort will be made to contact the child's parent(s) or guardian(s)..

In the event of a medical emergency do you hereby grant permission for the staff of Unifor Child Care Services

who are trained in emergency first aid and CPR to attend to your child?

Yes:

No:

B. In the event that you cannot be reached, do you hereby grant permission for a physician/hospital, as selected by

the Unifor Community Child Care & Developmental Services Inc., to hospitalize and/or secure proper treatment

for your child?

Yes:

No:

The Unifor Child Care & Developmental Services, Inc. are high profile programs. Do you hereby grant permission for

your son/daughter/ward to be video taped or photographed by public media or Unifor Public Relations?

Yes:

No:

Signature of Parent/Guardian

Date

Childcare Registration Form Page 2