Royal Child Care

Royal Child Care Registration Form

Please print clearly, many thanks.

Full name of child:

Usual name of child(if different):

Gender: M / F

Date of registration: Date of start:

Child’s date of birth:

Language:

Child's address:

Parent(Mother)/Guardian's information / Parent(Father)/Guardian's informatrion
Name: / Name
Address: / Address:
Home phone#: / Home phone#:
Cell phone#: / Cell phone#:
Occupation: / Occupation:
Work phone#: / Work phone#:
E-mail: / E-mail:

Person(s) authorized to pick up child:

Name: Relationship: Phone:

Name: Relationship: Phone:

Name: Relationship: Phone:

Person(s) not authorized to pick up child:

Name: Relationship: Phone:

Name: Relationship: Phone:

Name: Relationship: Phone:

Alternate person(s) to call and pick up child in case of emergency:

Name: Relationship: Phone:

Name: Relationship: Phone:

Name: Relationship: Phone:

Child's Immunization Status

Please attach a copy of your doctor’s records of your child’s immunization for the following immunization & ensure they are up to date.

DPT:(Diptheria, Pertussis, Tetanus) Poliomyelitis

MMR(Measles, Mumps, Rubella) HIB(Hemophilus Influenza-b Meningitis) Other immunizations given

Child’s Health Information

Name of child: Birth Date:

Care Card Number:

Family Doctor/Clinic Name: Phone:

General Health Of Child:

Normal Energy Level:

Any know health Problems? (handicaps, serious illnesses, etc):

Medications:

Has child had any communicable diseases? If so, which ones?

Are there any vision or hearing problems:

Allergies

Does your child have any allergies?

How severe is their reaction to their allergy?

Special instructions to follow should your child suffer an allergic reaction:

Has your child had surgery? ______If so, when/why:______
Does your child have any dietary restrictions:

Note: if your child requires an “epi-pen”, benedryl or any other allergy related medications to be kept on hand at the center, it is the responsibility of the parent to keep medications up to date and provide staff at Royal Child Care Center with a signed medical consent form allowing staff to administer these medications.

Child’s Personal Information

Number of adults at home: Pets:

Siblings: Name: Age:

Name: Age:

Name: Age:

Group experiences

What is/are your child's favourite toy(s)/activities:

Has your child had previous play group experience? Yes No

If yes, how did he/she adapt?

Does your child have any special fears?

Your child’s special likes? dislikes?

What kind of discipline is used at home:

Any unique gifts or needs you feel your child has?

What did you hope your child will gain from their daycare experiences:

Emergency Consent Form

Child’s Name: Date of Birth:

Home phone:

Address:

Mother’s Name: work/home phone:

Father’s Name: Work/home phone:

Alternate emergency Contact: Relationship:

Phone Numbers:

Child’s care card number:

Date effective: Gender:

Date of most recent tetanus shot:

Allergies/medications:

Permission / Consent for Emergency Care

1, It is our policy that we notify a parent when a child is ill or needs medical attention. Occasionally we contact either parent and we need to get immediate help for the child. Our procedure is to take the child to the nearest emergency service or call a medical practitioner or ambulance.

2, please sign the consent below and return it to the center immediately so that we can take appropriate action on behalf of your child. We will take this consent with us to the emergency center.

I authorize the staff at the child care center to call a medical practitioner or ambulance in the case of accident or illness of my child(ren), if the parent cannot immediately be reached.

Signature of Parent/Guardian: Date:

Manager of Facility:

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