Gitsegukla Headstart

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Gitsegukla Headstart

REGISTRATION FORM

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Date of Enrollment: ______Last date of Enrollment: ______

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Name: ______Address: ______

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D.O.B: ______

Male ______Female ______Phone:______

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Medical Insurance Number: ______

Photocopy Enclosed: Yes No (circle)

Band: ______Status Number: ______

Photocopy Enclosed: Yes No (circle)

Immunization Status:

Photocopy Enclosed: Yes No (circle)

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Mother's Name: ______Phone: ______

Clan: ______Cell: ______

House: ______Work: ______

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Father's Name: ______Phone: ______

Clan: ______Cell: ______

House: ______Work: ______

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Guardian: ______Phone: ______

Clan/House: ______Cell: ______

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Siblings: ______Age: ______

______Age: ______

______Age: ______

______Age: ______

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Doctor: ______Phone: ______

Dentist: ______Phone: ______

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Emergency Contacts:(Other than Parents)

1.Name: ______Phone: ______

Relationship to child:______Cell: ______

2.Name: ______Phone: ______

Relationship to child:______Cell: ______

3.Name: ______Phone: ______

Relationship to child:______Cell: ______

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Persons Authorized to Pick Up My Child In Case Of Emergency:

1.Name: ______Phone: ______

Relationship to child:______Cell: ______

2.Name: ______Phone: ______

Relationship to child:______Cell: ______

3.Name: ______Phone: ______

Relationship to child:______Cell: ______

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Person(s) NOT PERMITTED ACCESS to the child: Non-Applicable (Circle and leave blank)

1.Name: ______

2.Name: ______

Gitsegukla Headstart Program MUST have copies of Legal Documents in child's file.

Photocopy Enclosed: Yes No (circle)

If more space is required, please attach to this registration. All documents will be treated as confidential.

Medical Concerns: Does the child have any medical problems, health concerns, diet restrictions and/or allergies of which the Gitsegukla Headstart Program should be aware of? ___yes ___no ( If No, please continue to next section).

____DiabetesTreatment: ______

____EpilepsyIf yes, has your child had a seizures in the past year? __yes ___no

____AllergiesAny causing life threatening response, which requires immediate medical care. Allergic to:

______Bee/Wasp

______Drug Allergy -______

______Food Allergy = ____seafood ___dairy ___fruit

____meat ___vegetable

____Nut___cereal

____other - ______

______Inhalant -Epithelia Panel, Mites, Moulds & Fungi, Pollen Panel

Medication carried ___yes ___no If Yes:______

____Respiratory Conditions, which might require medical emergency care.

______Asthma. If yes, has your child required medical care in the past year? ____yes _____no

____Other Medical Conditions

______Heart Condition ______Blood Disorder

______Immune System Disorder

______Other Serious Chronic Condition - ______

____RestrictionsAre there restrictions (food, activities to avoid)?

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____Potty Trained, or in the process of potty training (circle). Any special instructions

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Gitsegukla Headstart Program Policy states staff WILL NOT ADMINISTER medication.

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In case of emergency, I hereby give permission to qualified health personnel (family physician, school nurse, other outside emergency personnel or staff who possess a valid First Aide Certificate) to provide treatment for my child. I understand that the staff of Gitsegukla Headstart Program and the Gitsegukla Community Education Development Authority Association Board of Directors are NOT responsible for medical care costs.

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Parent/Guardian SignaturePrintDate

Bus Sign Up and Consent

I would like to sign my child up for the Gitsegukla Headstart Program Bus Service. I understand that this service is available on school days, Monday to Friday, between 8:30 am - 9:00 am, 12:08-12:30 pm, 12:30 -1:00 pm, 3:08 - 3:30 pm with the exception to School/Statutory Holidays, Professional Development (Pro D), Community Interaction & Administration Days and when otherwise booked. I also understand that riding the school bus is a privilege and the Bus Policy must be followed to ensure safety of all children and staff. It is Gitsegukla Headstart Program Policy that parents/guardians that utilize this service, must ensure someone is home to receive your child at the end of school. Parents/Guardians must met and/or wave to the teacher/bus driver to indicate that they are home. Courtesy Bus Signs are available at Gitsegukla Headstart Program.

I give my permission for my child, ______to ride on the Gitsegukla Elementary / Headstart School Bus.

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Parent/Guardian SignaturePrintDate

Nature Walk Permission

During the School Year, Gitsegukla Headstart Program students will have the opportunity to go on Nature Walks within the Gitsegukla Reserve. I give my permission for my child, ______to go on Nature Walks in the _____/_____school year, with his/her class at the Gitsegukla Headstart Program.

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Parent/Guardian SignaturePrintDate

Picture/Video Consent Form

I hereby give Gitsegukla Headstart Program, Gitsegukla Community Development Authority Association the absolute and irrevocable right and permission with respect to the photographs/video that has been taken of my child, ______in which he/she ,may be included with others:

a).To copyright the same in the Gitsegukla Headstart Program's name

b).To use, re-use, publish and re-publish the same or in part, separately or in conjunction with other photographs/videos, in any medium now or hereafter known, and for any purpose whatsoever, including (but not limiting) illustrations, promotion, advertising and trade; and

c).To use Gitsegukla Headstart Program's name or my child's name in connection therewith if he/she decides.

I hereby release and discharge Gitsegukla Headstart Program, Gitsegukla Community Education Development Authority Association from all and any claims and demands ensuing from or in connection with the use of photographs/videos, including any and all claims for libel and invasion of privacy. This authorization and release shall insure to the benefit of legal representatives, licenses and assigns of Gitsegukla Headstart Program, Gitsegukla Community Education Development Authority Association as well as the person(s) for whom took the photographs/videos.

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Parent/Guardian SignaturePrintDate

Gitsegukla Headstart Program is a Licensed facility, 303 Preschool (30 months to school age). Children must be 3 years of age by December 31 to start. All Children must be POTTY TRAINED.

REGISTRATION FORMS MUST BE COMPLETED EACH YEAR.

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