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Fillable Printable Child Registration Form - Canada

Fillable Printable Child Registration Form - Canada

Child Registration Form - Canada

Child Registration Form - Canada

CHILD'S STARTING DATE: SEX: DATE OF BIRT H:
______/ ______/ ______ M ____ F __________/ ______/ ______
YY MM DD YY MM DD
NAME OF CHILD:______________________________________________________________________________________________
(Surname) (Given Names) (Also Known As)
Name the Child responds to: ____________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________
Postal code: __________________________________________________ Phone: _________________________________________________
Person(s) with whom the child lives (adults and children): _____________________________________________________________________
Child's first language: ________________________________ Other languages: ___________________________________________________
Parent(s) / guardian(s):
Name: __________________________________ Home phone: _____________________________ Cell phone: ________________________
Work phone: ____________________ Days/hours of work: ________________________________ E-mail: ____________________________
Name: __________________________________ Home phone: _____________________________ Cell phone: ________________________
Work phone: ____________________ Days/hours of work: ________________________________ E-mail: ____________________________
Person(s) authorized to pick up the child and be contacted in case of emergency. These people should be available during hours of care.
(include mother / father / guardian):
Name: ___________________________________________________________________ Relationship to child: _________________________
Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________
Name: ____________________________________________________________________ Relationship to child: ________________________
Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________
Name: ____________________________________________________________________ Relationship to child: ________________________
Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________
Name: ____________________________________________________________________ Relationship to child: ________________________
Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________
If appropriate, list an English speaking contact:
Name: ____________________________________________________________________ Phone: ____________________________________
Has the child previously attended davcare/preschool?
YES NO Comments:______________________________________________________________________________________
Comments/instructions to help us care for your child. (Pl ease feel free to add ad di tional pages.):
Toileting/Diapering (special words): _______________________________________________________________________________________
Rest Time (special comfort – toy/blanket): __________________________________________________________________________________
Eating/Mealtime (include food likes/dislikes): _______________________________________________________________________________
Fears: _______________________________________________________________________________________________________________
CCFL2 09-09
Name of Facility:
Please tell us anything else you think will help us provide an enriching experience for your child: ________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
HEALTH INFORMATION
Health professionals involved with your child (other than doctor and dentist):
NAME PROFESSION/AGENCY
____________________________________ _________________________________________ Phone: __________________________
____________________________________ _________________________________________ Phone: __________________________
____________________________________ _________________________________________ Phone: __________________________
Does your child have:
A medical condition/concern? YES NO
If yes, please provide further information: __________________________________________________________________________________
Allergies? YES
NO
If yes, please provide further information: __________________________________________________________________________________
Asthma? YES
NO
If yes, please provide further information: __________________________________________________________________________________
Has your child had a seizure in the past year? YES
NO
If yes, please provide further information: __________________________________________________________________________________
Does your child require a special diet related to a medical condition? YES
NO
If yes, please provide further information: __________________________________________________________________________________
Food sensitivities? YES
NO
If yes, please provide further information: __________________________________________________________________________________
List all prescription and “over the counter” medications your child receives:
Medication Times Given Reason for Medication
____________________________________ _____________________________________________________________________
________________________________________ __________________________________ ____________________________________
You may be asked to complete additional forms if you answered yes to any of the above.
This health information may be made available to the staff of Vancouver Coastal Health.
This health information may be made available to the staff of Vancouver Coastal Health.
Office Use Only
Date Child Leaves the Facility: DATE: ________/______/______
YY MM DD
Regional 2009 Provided by VCH COMMUNITY CARE FACILITIES LICENSING
Custody Agreement YES N/A Provided to Facility YES NO N/A
Immunization Documents Returned to Facility YES NO
Information Provided By: _______ _______________________ ___________ _____________________
Print Name Signature
DATE: ________/______/______
YY MM DD
Information Received By
: _______ _____________________ __ ___________ _____________________
Print Name Signature
DATE: ________/______/______
YY MM DD
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