Registration Form

PERSONAL INFORMATION

FULL NAME OF CHILD(Required)
USUAL NAME OF CHID (if different)
MM slash DD slash YYYY
GENDER
MM slash DD slash YYYY
ADDRESS(Required)
MOTHER OR GURDIAN NAME(Required)
FATHER OR GURDIAN NAME(Required)
FATHER'S ADDRESS(if different from above)
MOTHER'S ADDRESS(if different from above)
MOTHER'S WORK ADDRESS(Required)
FATHER'S WORK ADDRESS(Required)

EMERGENCY HEALTH INFORMATION

CHILD’S IMMUNIZATION STATUS

IS YOUR CHILD UP TO DATE ON IMMUNIZATION?(Required)

CONSENT FOR EMERGENCY CARE

I authorized the staff at the child care centre to call a medical practitioner or ambulance/ transport child to emergency medical care, in the case of accident or illness of my child, if the parent cannot immediately be reached.(Required)

HEALTH INFORMATION

INJURY(S), ILLNESS(ES) OR OPERATIONS YOUR CHILD HAS HAD INCLUDE DATE(S) 1. Please describe any concern(s) / issues regarding your child’s health (seizures, asthma, vision, hearing, etc.) 2. Please describe any concerns you may have regarding your child’s development (Behaviour, vision, hearing, speech, language, mobility. Etc.) 3. Please any specific care instruction regarding 1) and/or2) above.
(e.g. occupational therapist/ physical therapist) ALTERNATE PERSONS AU

ALTERNATE PERSONS AUTHORIZED TO PICK UP CHILD

(other than parent/ guardian listed above, include emergency pickup) Check all that apply
NAME(First One)(Required)
NAME(Second One)(Required)

PERSONS WHO ARE NOT PERMITTED ACCESS TO MY CHILD

NAME(First One)
NAME(Second One)

SIGNATURE OF PARENT OR GURDIAN PROVIDING INFORMATION

NOTE: This information may be reviewed by Fraser Health Licensing staff as per legislation.
Name(Required)
MM slash DD slash YYYY