Child Registration Form - Canada

CHILD'S S TARTING DATE: SEX: DATE OF BIRTH:
______/ ______/ ______ 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. (P l ease feel free to add ad di tional p age s.):
Toileting/Diapering (special words): _______________________________________________________________________________________
Rest Time (special comfort – toy/blanket): __________________________________________________________________________________
Eating/Mealtime (include food likes/dislikes): _______________________________________________________________________________
Fears: _______________________________________________________________________________________________________________
CCFL2 09-09
Name of Facility:
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