Please download full copy of Parent Handbook at www.myprovidencedaycare.ca
Providence Daycare Centre
Registration Form
Last Name: First Name:
Preferred Name: Middle Name:
Birth Date: Start Date:
PARENTS OR GUARDIANS
(1) Last Name: First Name:
Relationship to Child: Email:
Address:
City: Postal Code:
Home Phone:
Cell Phone:
Work Phone:
Employer:
Work Address:
(2) Last Name: First Name:
Relationship to Child: Email:
Address:
City: Postal Code:
Home Phone:
Cell Phone:
Work Phone:
Employer:
Work Address:
EMERGENCY CONTACT
Name: Relationship to Child:
Address:
Home Phone:
Cell Phone:
Work Phone:
Please download full copy of Parent Handbook at www.myprovidencedaycare.ca
Name: Relationship to Child:
Address:
Home Phone:
Cell Phone:
Work Phone:
AUTHORIZATION FOR PICKUP
Your child will only be released to an authorized person listed on this form
(parent/guardian and/or emergency contact). In case of an emergency or an unforeseen
circ*mstance, please indicate the name, address and phone number of any other person/s
who you authorize to pick up your child on your behalf.
Name Address Phone
. . .
. . .
. . .
A parent/guardian's verbal authorization for pickup must be received before your child
will be released to anyone not listed here. If not received, and we cannot notify you by
phone, the child will not be released. Please note that the person picking up must provide
Photo Identification and Contact Information before child can be released.
MEDICAL INFORMATION
Doctor: Office Phone:
Address:
City: Postal Code:
Health Card# (Optional):
Allergies:
Medical Information:
Medication:
ADDITIONAL INFORMATION (including, asthma, dietary requirements, rest,
exercise):
Please download full copy of Parent Handbook at www.myprovidencedaycare.ca
IMMUNIZATION: The Child Care and Early Years Act requires that we have a
photocopy of your child's recent immunization record in our files. Please include a
photocopy with this registration form. If you do not have the records, a copy can be
obtained from your Doctor.
COMMUNICABLE DISEASES (check those that your child has had): CHICKEN POX:
MEASLES
GERMAN MEASLES
PNEUMONIA
RHEUMATIC FEVER
WHOOPING COUGH
FIFTH DISEASE
FREQUENT COLDS
BRONCHITI
MIDDLE EAR INFECTION
TONSILITIS
SCARLET FEVER
DROP OFF AND PICK UP TIMES
DROP OFF PICK UP
Monday
Tuesday
Wednesday
Thursday
Friday
It is understood that my child will be expected to be involved in all aspects of the program to the
best of his/her ability. Such involvement includes, but is not limited to, centre based play, indoor
and outdoor gross motor activities and rest time. If your child is unable to function within our
classroom environment, due to illness, we may ask that he/she remain at home. I understand the
above statement and agree to keep my child home when ill. I am aware that I will be expected to
make arrangements for early pick up if my child is ill during the day.
Signature of Parents: ___________________________ Date: ______________
Signature of Director/Supervisor: _________________________ Date: ______________
Please download full copy of Parent Handbook at www.myprovidencedaycare.ca
DAYCARE USE ONLY
Room Registered: Days Registered:
Start Date: End Date:
Registration Received: Deposit Received: Deposit Returned:
Immunization Received:
Please download full copy of Parent Handbook at www.myprovidencedaycare.ca
PARENT CONSENT FORM
CHILD’S NAME: ___________________________________________________________
*************************************************************************
FIELD TRIPS
I hereby give consent for my child to participate in excursions, within walking distance of the
centre, under the guidance of the staff of Providence Daycare Centre.
_____ My child may participate in the above field trips.
_____ My child may not participate in the above field trips.
*************************************************************************
MEDICAL ATTENTION
In the event of an emergency, I understand and agree that my son/daughter, will receive:
Whatever first aid is available
Whatever additional medical assistance is required and available
Such other emergency assistance as may be required to safeguard life and/or prevent injury
I understand further that I will be informed of the situation as soon as possible and that initial
contact will be attempted by calling the telephone number(s) noted in the registration form.
_____ I give consent for my child to be transported by transportation arranged by Providence
Daycare Centre (ambulance, taxi, etc…) as required.
_____ I do not give consent for my child to be transported by transportation arranged by
Providence Daycare Centre (ambulance, taxi, etc…) as required.
*************************************************************************
VIDEOTAPE/PHOTO CONSENT FORM
From time to time, staff will videotape or photograph the children at Providence Daycare Centre.
Both the photos and videos are useful for staff training and community and educational awareness
purposes. Occasionally, they may appear in the newspapers. Please indicate ONE of the following
choices.
_____ I give consent for Providence Daycare Centre staff to use videotapes/photos of my
child(ren) for classroom and day-care use only.
_____ I give consent for Providence Daycare Centre staff to use videotapes/photos of my
child(ren) for uses inside and outside the day-care.
_____ I do not give consent for videotapes/photos to be taken of my child in any capacity.
Please download full copy of Parent Handbook at www.myprovidencedaycare.ca
BACKGROUND INFORMATION
CHILD’S NAME: ___________________________________________________________
1. Brothers or sisters:
____________________________________________________________________
2. Favourite friend, relative or babysitter, real or imaginary:
____________________________________________________________________
3. It is important that my child learns:
____________________________________________________________________
4. Favourite place to go:
____________________________________________________________________
5. Activities their family do together:
____________________________________________________________________
6. What the child does when upset, how can we comfort them:
____________________________________________________________________
7. Toilet trained:
____________________________________________________________________
8. Any other services involved with the child:
____________________________________________________________________
Please download full copy of Parent Handbook at www.myprovidencedaycare.ca
EMERGENCY CLASSROOM RECORD
Name of Child: ____________________________________________
Health Card Number (Optional):________________________________________
Date of Birth:________________________________________________
Mother’s Name: Father’s Name:
Home Address:
Home Address:
Home Phone:
Cell Phone:
Home Phone:
Cell Phone:
Work Address:
Work Address:
Work Phone: Work Phone:
Doctor’s Name:
Doctor’s Address:
Doctor’s Phone:
Emergency Contacts
Name: Name:
Home Address:
Home Phone:
Home Address:
Home Phone:
Cell Phone: Cell Phone:
Work Phone: Work Phone:
Allergies and/or Special Medical/Additional Information:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Symptoms of Ill Health:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
Please download full copy of Parent Handbook at www.myprovidencedaycare.ca
PROGRAM FEES
Toddler Program
Full Time:
Current Amount/Day: _______________
Part Time
Current Amount/Day: ________________
Preschool Program
Full Time
Current Amount/Day: ________________
Part Time
Current Amount/Day: ________________
Child care fees are payable to Providence Daycare Centre on the 1st and 15th of every month.
There is a late fee charge of $5.00 per day effective on the 2nd or 16th day of the month. If fees
are not submitted by the 17th day of the month, a letter will be issued which states that child care
service will be terminated immediately. The charge for NSF cheques is $45.00. Providence
Daycare Centre will be accepting payments only by cash, money order and preauthorized
payments.
A Void Cheque or Preauthorized Deposit Form is required at time of registration.
REGISTRATION FEE
Per family: Please call to verify current amount: ___________________
DEPOSIT
Please call to verify current amount for desired Centre location: ____________
Parents are required to provide one (1) month written notice of withdrawal. Failure to provide
adequate notification will result in the forfeiture of the deposit paid at the time of registration.
I have read and understand Providence Daycare Centre's fee payment and agree to abide by the
policy.
Signature of Parents: _____________________________________ Date: ______________
Signature of Director/Supervisor: __________________________ Date: ______________
Please download full copy of Parent Handbook at www.myprovidencedaycare.ca
Providence Daycare Centre
SUNSCREEN CONSENT AND RECORD
Research shows that sun exposure during childhood and adolescence is strongly linked to the
development of skin cancer later in life. Infants and children have thinner skin than adults, making
them more sensitive to ultraviolet rays.
Providence Daycare Centre staff is hereby authorized to administer sunscreen.
CHILD’S NAME
______________________________________________________________________________
DATE:
______________________________________________________________________________
SIGNATURE OF PARENT/GUARDIAN
______________________________________________________________________________
