Preschool Registration Form (Page 2 of 3) in pdf

Language(s) spoken at home: ____________________________________________________

Please Indicate:

Authorized person(s) (other then yourself) to whom your child may be released to:

a) ________________________________ b) _____________________________________

Person(s) your child is NOT to be released to:

a) ________________________________ b) _____________________________________

KIDS PALACE PRESCHOOL HEALTH RECORD INFORMATION

Name of Family Doctor: __________________________________________________________

Physical Address: _______________________________________________________________

City: _________________________________________ Postal Code: _____________________

Phone Number: ________________________________

Number of:

Brothers

Sisters

Younger

_____

Older

_____

My child’s immunizations are up to date for my child’s age: Yes_______ No_________

Does your child have any medical conditions, allergies, emotional or developmental challenges

requiring or receiving treatment or supervision? If yes, please explain:

Emergency Contact (other than parents) within 20 km of Carstairs

Name: _______________________________ Phone: ___________________________________

Physical Address: _______________________________________________________________

City: _________________________________________ Postal Code: _____________________

Name: _______________________________ Phone: ___________________________________

Physical Address: _______________________________________________________________

City: _________________________________________ Postal Code: _____________________

I CONSENT TO EMERGENCY MEDICAL TREATMENT FOR MY CHILD

In an emergency, my child may need medical or surgical treatment. If an emergency occurs,

every reasonable effort must be made to contact to me. If I cannot be reached, I give my

permission to emergency medical treatment for my child. Any expense incurred for emergency

medical treatment will be my own responsibility.

Yes, I Agree __________________

Preschool Registration Form Page 2