Registration Form

PERSONAL INFORMATION

FULL NAME OF CHILD(Required)

First Last

USUAL NAME OF CHID (if different)

First

CHILD DATE OF BIRTH(Required)

GENDER

Male

Female

Starting Date(Required)

ADDRESS(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

MOTHER OR GURDIAN NAME(Required)

First Last

FATHER OR GURDIAN NAME(Required)

First Last

Mother's Email Address

Father's Email Address

FATHER'S ADDRESS(if different from above)

Street Address City State / Province / Region ZIP / Postal Code Country

MOTHER'S ADDRESS(if different from above)

Street Address City State / Province / Region ZIP / Postal Code Country

MOTHER'S TELEPHONE NUMBER(Required)

FATHER'S TELEPHONE NUMBER(Required)

MOTHER'S WORK ADDRESS(Required)

Street Address City State / Province / Region ZIP / Postal Code

FATHER'S WORK ADDRESS(Required)

Street Address City State / Province / Region ZIP / Postal Code

MOTHER'S CELL PHONE(Required)

FATHER'S CELL PHONE(Required)

EMERGENCY HEALTH INFORMATION

CARE CARD NUMBER(Required)

FAMILY DOCTOR/CLINIC NAME(Required)

DOCTOR/CLINIC TELEPHONE(Required)

CHILD’S IMMUNIZATION STATUS

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

YES

NOT IMMUNIZED

COMMENTS

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)

YES

HEALTH INFORMATION

REGULAR MEDICATION(S) AND REASON FOR(please list)(Required)

ALLERGIES TREATMENT OF(please list)

INJURY(S), ILLNESS(ES) OR OPERATIONS YOUR CHILD HAS HAD INCLUDE DATE(S)

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.

OTHER HEALTH CARE PROFESSIONAL INVOLVED IN YOUR CHILD LIFE

(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)

First Last

RELATIONSHIP(Required)

TELEPHONE(Required)

NAME(Second One)(Required)

First Last

RELATIONSHIP(Required)

TELEPHONE(Required)

PERSONS WHO ARE NOT PERMITTED ACCESS TO MY CHILD

NAME(First One)

First Last

RELATIONSHIP

TELEPHONE

NAME(Second One)

First Last

RELATIONSHIP

TELEPHONE

SIGNATURE OF PARENT OR GURDIAN PROVIDING INFORMATION

NOTE: This information may be reviewed by Fraser Health Licensing staff as per legislation.

Name(Required)

Name and Family

Date(Required)