Little Pumpkins Inc

Little Pumpkins Inc

Registration form.

Childs last name ______Childs first name ______Known as______

DoB (D/M/Y)______Age_____Address______Post code______

Mother/Guardian name ______Email______Address______

Telephone: Home ______Work ______Cell______Work place______

Father/Guardian name ______Email______Address______

Telephone: Home______Work______Cell______Work place______

Emergency contacts Name # 1______Relationship to child______Telephone______

Emergency contacts Name # 2______Relationship to child ______Telephone ______

Who, other than child’s parents/guardians has permission to pick up the child from the centre?

Name______Relationship______Name______Relationship______

Name______Relationship______Name______Relationship______

Name______Relationship______Name______Relationship______

Other members of the household______

Previous nursery school/day care? ______Favourite play activities______

Special feeding/diet requirements? Yes/No ______

Toilet trained? Yes/No/In Progress. Any special rest or exercise requirements?______

Family Doctors Name ______Telephone Number______Address______

Are all immunizations up to date as recommended by the department of health? Yes/No

(A copy of immunization record is required.) MSI no.______

Has your child had any communicable diseases?______Is he/she on any medication? Yes/No______

Does your child have any known allergies? Yes/No Please specify______

Is your child under the care of a Doctor for any particular reason? Yes/No If yes, why?______

Date Placement required ______What days are you looking for?______

I/we apply for a place at Little Pumpkins Inc, ON THE TERMS AND CONDITION WITHIN THE PARENT POLICY MANUAL WHICH I HAVE RECEIVED, READ AND UNDERSTOOD. Upon placement being confirmed, I/we shall provide a booking fee of $30 which is non refundable. A deposit of one full month up front shall be paid prior to first attending date. This shall be refunded when my/our child leaves Little Pumpkins Inc or at Little Pumpkins Inc discretion used to reduce any outstanding debt owed by me/us to Little Pumpkins Inc when my/our child leaves.

Signed Parent/Guardian (1)______Parent/Guardian (2)______

Email:- Tel:- 1 902 365 5137

Permissions

I give my permission for my child to go on supervised walks or outings as part of the Little Pumpkins Program. I understand that I will be informed of major outings before they are taken and, that all ratio’s will be kept and emergency numbers will always be taken on any outing.

______

Parents Signature

I authorise the staff at Little Pumpkins to give consent for emergency medical treatment at the hospital or office of a physician in the event that immediate treatment is needed and I can’t be reached

______

Parent or guardian Signature

I give permission for my child______to have their photos displayed in the facilities scrap book or bulletin board, shown to current or prospective clients of Little Pumpkins.

______

Parent or guardian Signature

I give permission for my child______to have their photos displayed on Little Pumpkin’s website. No names shall be included

______

Parent or guardian Signature

I understand that it is my responsibility to update this form in the event that I no longer wish to authorize one or more of the above. I agree that this form will remain in effect during the term of my child’s enrollment.

Signed ______Date______

(Parent or guardian Signature and date)