REGISTRATION FORM – 4 Year Old Program

September – MaySchool Term

Session Information / Fee Remittance: Cash ______Cheque ______
Session Preference (please indicate 1st, 2nd 3rd, and 4th choices)
Monday/Wednesday:9-11 AM_____ 12:45 – 2:45 PM______
Tuesday/Thursday: 12:45 – 2:45 PM______
Friday:9-11 AM_____
Child’s Personal Information / Please fill this form in COMPLETELY with the following information for licensing purposes. Please provide a legal land description for a rural address, or a full street address for an in-town residence for both personal and emergency contacts.
Child’s Given Name: ______M / F (circle)
FirstLast
Date of Birth______AHC No.______
Physical Address ______City/Town ______Postal Code______
(legal land description or street address)
Mailing Address if different from above.______
Name Child Goes By: ______Names and ages of siblings: ______
______
Parent Information / Mother / Father
Name
Home Address
If different from above
City/Town
Postal Code
Home Phone
Employer
Work Phone
Cell Phone
Email
Sign In/Out / Names of Parent(s) and/or person(s) authorized to sign your child in and out of our care:
______
______
______
Emergency Contact / Who we should contact in case of emergency, DURING PROGRAM HOURS when parents/guardians are not available? Please list TWO contacts.
Emergency Contact Name / Emergency Contactcompleteaddress (street or land location) / Phone Number
Medical Information / Has your child ever had a speech, hearing, or behavioural assessment done? ______
If so, where? ______
What was the outcome of the assessment? ______
______
If circling yes to any of the following, please provide details / Please Circle Yes or No
Immunizations up-to-date / YN
Long-Term Medication / YN
Drug Allergies / YN
Food Allergies / YN
Special Needs / YN
Is Your Child Prone To: / Ear Infection / YN
Hay Fever / YN
Epilepsy / YN
Asthma / YN
Colds / YN
Speech Problems / YN
Hearing Problems / YN
Temper Tantrums / YN
Eye Problems / YN
Nose Bleeds / YN
Finger/Thumb Sucking / YN
Nail Biting / YN
Shyness / YN
Other (please describe) / YN
Authorization / In the event of an emergency, when my child may need first aid or transportation to a medical facility, I give my permission for first aid to be given or for such transportation to take place.
Date:______Signature: ______
I have received and read the Discipline Policy (page 3 of the Parent Handbook) of the program.
Date:______Signature: ______

"How did you hear about Mother Goose Playschool?" Please check all that apply...... Family/Friend Referral ___Signage ___Website ___Facebook Page ___Newspaper ___Poster (Grocery store, library)___ Other ___

REGULATION 29:

PORTABLE EMERGENCY INFORMATION RECORD MUST INCLUDE:

Child’s Name:______
Alberta Health Care No.
Child’s Address: ______
Date of Birth: ______
______/ ______
Mother’s Name ______/ Father’s Name: ______
Mother’s Home Address: ______/ Father’s Home Address: ______
City: ______Postal______/ City: ______Postal______
Mother’s Home Phone: ______/ Father’s Home Phone: ______
Mother’s Cell Phone: / Father’s Cell Phone:
Where to reach parents during Playschool hours:
Telephone: ______/ Telephone: ______
In case of an emergency, the child may be released to:
Emergency #1 (complete street or land location
address) / Emergency #2 (complete street or land location
address)
Name: ______
Address:______
City/Town:______
Telephone:______/ Name: ______
Address:______
City/Town:______
Telephone:______
Please Circle Yes or No
Is child’s immunization up-to-date? / YesNo
Any health information (i.e. allergies, long term medication etc.? If yes please list below) / YesNo