Child

First Name *

Middle Name *

Last Name *

Child Date of birth *

Health Care Number

Start Date

Address *

Parent/Guardian 1

Relation Ship With Child *

Guardian 1 First Name *

Guardian 1 Last Name *

Address (if not the same)

Phone Number *

Work Number

Email *

Parent/Guardian 2

Relationship to child *

Guardian 2 First Name *

Guardian 2 Last Name *

Guardian 2 Address

Guardian 2 Phone Number *

Guardian 2 Work Number

Guardian 2 Email Address *

Name of anyone who is NOT legally allowed to pick up my child (please provide document) *

NOT legally allowed to pick up my child Document

Medical Information

Allergies & Food Restrictions *

Medical Conditions *

On Going Medication(dosage)

Immunization Up to date? *

Yes

Emergency Contact & Authorization for Pickup

Your child will only be released to an authorized person listed on this form (parent/guardian and/or emergency contact). These contacts will be called a) in case of emergency, b) if parents/ guardians are late, or c) possible infection or illness is present. In case of an emergency or an unforeseen circumstance, please indicate the name, address and phone number of any other person/s who you authorize to pick up your child on your behalf (ID will be required). A parent /guardian's verbal authorization for pickup must be received before your child will be released to anyone not listed here. If not received, and we cannot notify you by phone, the child will not be released. Please indicate if the person is emergency contact only or if he/she is also authorized to pick up your child.

Emergency Contact 1 Name *

Emergency Contact 1 Relation with Child *

Emergency Contact 1 Address *

Emergency Contact 1 Telephone *

Emergency Contact 2 Name

Emergency Contact 2 Relation with Child

Emergency Contact 2 Address

Emergency Contact 2 Telephone

Emergency Consent

In case of accident or serious injury a child, the license holder or staffs on duty must immediately ensure that CALL 911 IMMEDIATELY, the child receives medical attention if necessary decided by 911. The child’s parent is notified. If an ambulance is required, it will be the cost of the parents or guardians

In case of accident or minor injury a child, the license holder or staffs with first aid certificate will give first aid to the child as needed.

Child's History and Relevant Information

Child will arrive at

Child will be picked up at

Typical reaction to stress?

Typical reaction to illness?

Any particular fears?

Is your child toilet trained?

Yes

Child is predominantly

Left handed

Right-handed

Child's first language *

Other Languages *

The goal for my child

I give my consent to let my child be photographed by The Champions Academy Child Care/OSC staff to be displayed in day care premises

Yes

I give my consent to allow my child to be displayed on picture/s with other child/children from the The Champions Academy Child Care / OSC that may be distributed to all parents of our Centre

Yes

I give my permission for my child to participate in annual screening procedures done at the center to determine the growth and development of my child, such as hearing, vision and developmental stages. I understand that I will be notified in advance of all scheduled screening procedures.

Yes

I give my permission to allow the staff of The Champions Academy Child Care / OSC to take my child to neighbourhood walks/parks/library

Yes

Note* Our day care does not share your child’s information with anyone unless you give us written or verbal consent. We adhere to the rules of the freedom of information and Privacy Act.

I have read and understood all the details of the “Registration Form”. I agree to abide terms & conditions by the above regulations of the Center.

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