ENROLLMENT FORM

Please note: This registration form is for your child’s records and protection while attending Building Blocks Childcare Centre’s. All fields must be filled in to there entirety to be accepted prior to registration. Please fill out the form online and print for your personal signatures. Thank you

Child's Full Name

Nickname

Birth Date

Date of Enrollment

Address

City

Province

Postal Code

Home Phone

Alberta Health Care Number

Mother's Full Name

City

Mother's Address

Province

Postal Code

Mother's Home Phone

Mother's Employer

Work Phone

Ext

Pager or Cell#

Father's Full Name

City

Father's Address

Province

Postal Code

Father's Home Phone

Father's Employer

Work Phone

Ext

Pager or Cell#

Emergency Contact and Persons Authorized to Remove Child from Day Care

Emergency Contact (other than parents/guardian): MUST BE A LOCAL ADDRESS

Name

Home Phone

Cell/Pager

Work Phone

Emergency Contact Address

Province

Postal Code

Relationship to Child

Person(s) authorized to pick up my child (Besides Parents/Guardians or Emergency Contacts):

Name

Phone

Name

Phone

MEDICAL INFORMATION

Child's Physician

Phone

Regular Medications

Medicine Allergies

Food Allergies

Any Other Allergies

Are your child’s Immunizations up to date?

Yes

Is your child toilet trained? If not please provide further details

Are there any special learning needs (e.g. speech therapy, physical therapy, occupational therapy, learning disability, CHADS, etc.) the school should be aware of which would relate to the programming needs for your child? (Please circle and describe if yes)

Yes

Please tell us why you are registering your child in day care?

"Enrollment"

ENROLLMENT FORM

Emergency Contact and Persons Authorized to Remove Child from Day Care

Emergency Contact (other than parents/guardian): MUST BE A LOCAL ADDRESS

Person(s) authorized to pick up my child (Besides Parents/Guardians or Emergency Contacts):

MEDICAL INFORMATION

EMERGENCY RELEASE

Consent to Emergency First Aid & Transportation

Consent to Medical Care and Treatment

Nature of First Aide

Custody Order

Parent Handbook Policies

Neighborhood Walks

Activities that are not supervised by a primary stafft:

Release of Information to agreed upon agencies

Consent to Apply Sunscreen

Consent for Photos on Facebook