BROOKSWOOD KIDS’PLACE

REGISTRATION FORM

CHILD’S NAME (please print):

 

SEX:

 

ADDRESS (Please include): Street   # Street    City     Postal Code

 

TELEPHONE:

BIRTHDATE: DD/MM/YY

 

AGE:

 
YOUR CHILD IS REGISTERED FOR:

 

︂PRESCHOOL ︂ KINDERCARE

︂ OSC (out of school care)

 DETAILS (# days per week, AM or PM only etc):

 START DATE:____________ END DATE:_________________

PARENT(S) OR GUARDIAN(S):

NAME (please print): ____________________________________

HOME PHONE: ___________________ WORK PHONE: __________________

CELL PHONE: ____________________email:___________________________

NAME (please print): ________________________________________

HOME PHONE: ____________________ WORK PHONE: _________________

CELL PHONE: email:

EMERGENCY CONTACT(S) (IN CASE PARENTS CANNOT BE LOCATED)

NAME:_________________________________ PHONE: _____________________

RELATIONSHIP TO CHILD:_____________________________________________

NAME:_______________________ PHONE: _____________________

RELATIONSHIP TO CHILD:_____________________________________________

The following people will be authorized to pick up my child from the Centre. Staff will not allow my child to go home with anyone else, unless I give permission in writing and identification is provided by the pickup person.

NAME:

RELATIONSHIP:

 

NAME:

RELATIONSHIP:

 

NAME:

RELATIONSHIP:

When I enroll my child(ren) at Brookswood Kid’s Place, I automatically become a member of the society. This membership entails certain responsibilities with regards to management, operations and regulations of the centre as made and amended by the board of directors.

PARENT OR GUARDIAN SIGNATURE:

CENTER SUPERVISOR’S SIGNATURE:

 

BROOKSWOOD KID’S PLACE

REGISTRATION FORM: MEDICAL INFORMATION

CHILD’S NAME (Please print):

 

FAMILY DOCTOR: _________________________________

 

FAMILY DENTIST: __________________________________

 

 

PHONE: ________________

PHONE: ________________

MEDICAL PLAN NO.:

ALLERGIES – LIST OF PRODUCTS:

 

 

SPECIAL INSTRUCTIONS CONCERNING ALLERGIC REACTIONS:

 

 

VISION OR HEARING PROBLEMS:

LIST OF COMMUNICABLE DISEASES CHILD HAS HAD:

 

 

HAS YOUR CHILD RECEIVED IMMUNIZATIONS?

RECORD OF IMMUNIZATIONS AS SUBMITTED BY THE PARENT/GUARDIAN

DIPHTHERIA/PERTUSSIS/TETANUS

DATES:

POLIOMYELITIS

DATES:

M/M/R (MUMPS, MEASLES, RUBELLA)

DATES:

ADDITIONAL MEDICAL INFORMATION AND COMMENTS:

 

 

I understand that the information contained on this medical form will be used by Staff in the event of an emergency and that Staff are not responsible for any false information contained here.

PARENT OR GUARDIAN SIGNATURE:

CENTER SUPERVISOR’S SIGNATURE:



 BROOKSWOOD KID’S PLACE

 REGISTRATION FORM: MEDICAL CONSENT

 

 

Consent for ill or injured child to be taken to the nearest emergency in the event that a parent cannot be reached.

 

 

 

It is our policy that we notify a parent when a child is ill or needs medical attention. Occasionally we cannot contact parents and we need to get immediate help for the child. In this case our procedure is to have the child taken by ambulance to the nearest emergency service.

Please sign the consent below so that we can take appropriate action on behalf of your child.

I herby give consent for my child ___________________to be taken to the nearest emergency facility in the event that I cannot be contacted. I understand and consent to the medical attention given by the attending medical practitioners.

Parent/Guardian signature:______________________________________________________

Date: ___________________________