Registration Form for Child Care

Date of Enrollment: __________________________

Name of Child: _____________________________ Birthdate: ____/____/____ Sex: M __ F __

Full name of Parent(s)/Guardian:

1. ____________________________________________________________

2.
____________________________________________________________

Address:

Street: _________________________________________________________

City: _________________________  Post Code: _________________________

Telephone Numbers: Mobile: _____________________ WORK: ____________________

Home  _____________________          ____________________

Parent’s Email address: _______________________________________________

Child Care Card Number: ______________________

Family Doctor: _________________________  Doctor Phone Number: ________________________

PERSONS AUTHORIZED TO CALL FOR THE CHILD AND CONTACT IN EMERGENCY:

Name Telephone Number

1.
_______________________________________________ ___________________________

2.
________________________________________________ ___________________________

Names of other children in family: ___________________________ Birthdate: ______________

______________  (yy/mm/dd)

Has the child had previous experience away from home? NO YES If YES, explain:

____________________________________________________________________________________.

Do you think your child feels comfortable leaving parents? NO YES If YES, explain:

____________________________________________________________________________________.

Special instructions concerning Care, Medication, Diet,

____________________________________________________________________________________.

or Custody:

NO 

YES                         ATTACH
DOCUMENTATION

HEALTH HISTORY

Has this child any known health problems or depressed immune system?

NO 

YES                         ATTACH
DOCUMENTATION

List communicable diseases child has had:

Has he/she had any recent illness?

NO 

YES                         ATTACH
DOCUMENTATION

Any allergies?

NO 

YES                         Allergens

Attach special instructions to follow in the event of an allergic reaction.

What are the child’s eating habits?

Favorite foods:

Strong dislikes:

Basic Schedule and Record of Immunization as submitted by Parent or Guardian

(ATTACH IMMUNIZATION RECORD OR RECORD THE DATES)

Date (yy/mm/dd)                                                                           

Child pickup authorisation

I authorize the following individuals to pick up my child from the child care:

1. Name:
________________________________ Phone: _____________________

2. Name:
________________________________ Phone: _____________________

If an authorized
individual without valid identification or an unauthorized individual comes to pick up my child from child care, I can be contacted at this number:  _____________________________

Emergency
Medical Treatment Authorization

I give Wonder Years Daycare, and his/her employees permission to obtain emergency medical/dental treatment for my child, ________________________________

Child’s Physician: _____________________________ Phone: ___________________

Physician’s address:______________________________________________________

Child’s Care Care Number: ________________________________________________

Parent signature _____________________________

Medication
Authorization Form

The policy is medication will only be administered if it has been prescribed by a qualified medical practitioner, is in its original container and we have a signed permission form with directions.

I, ______________________________, parent of ____________________authorize Wonder Years Daycare to administer __________________________ (medication) to my child with the following instructions:  Dosage:__________________________________________________________________

Time(s):______________________________________________________________________

Special Instructions (ie: on full/empty stomach, etc.) ____________________________

Possible Side Effects: ______________________________________________________________

Parent signature _____________________________
Photograph Release/Permission Form

This is an agreement between Wonder Years Daycare and parent ______________________________.

I consent to the use of any photographs in which I or my child(ren) appear, taken by Wonder Years Daycare on _________________ For use in the ________________________

I give full copyright and permission to use my photograph in the above-named production and any subsequent presentation of that production and in any subsequent promotional materials such as newsletter and brochures.

Signature of parent ______________________      Date _________________________

Field Trip Authorization

General, Local Field Trip Authorization

I, ___________________________________ (parent) give Wonder Years Daycare, and employees (if applicable), permission to take my child,
______________________________ on short field trips and other outings as part of the Daycare program.  This includes transportation by car, bus, taxi, or on foot AND is granted only if my child will be appropriately restrained in any vehicle.

__________________________________________________________

Parent Signature                                                               Date

 Authorisations

• I am aware that the daycare provider will be visited from time to time by various community resource persons.                 Y         N
• I am aware that in case of an emergency, a substitute care provider may be used.               Y         N
• I agree that the care provider can apply sun care products to my child.      Y         N
• I agree that my child can be photographed by the daycare. (Parents will need to sign a RELEASE FORM before photos can be
  used for publicity purposes)            Y         N
• I agree that my child may go for walks in the neighbourhood with the care provider.          Y         N
• I agree that my child can travel with the care provider by bus/car. A signed OUTING PERMISSION FORM must be signed.           Y         N
• Usually, field trips will be to ___________________________________________________.
• For your child to attend special field trips, a sign CONSENT FORM must be completed before the event.    
• I have read the CONFIDENTIALITY POLICY              Y         N
• I have read the LOST CHILD POLICY      Y          N
• I have read the WELLNESS/ILLNESS POLICY             Y          N
• I have read the GUIDANCE POLICY             Y          N
• I have read the MEDICATION POLICY      Y          N
• I have read the EMERGENCY EVACUATION POLICY          Y          N
• I have read the REQUIREMENT TO REPORT SUSPECTED CHILD ABUSE POLICY           Y         N
• I have signed all applicable consent forms              Y          N.

I have read and understand the policies as outline in the parent’s booklet.

_____________       ________________________                                  _____________________________

Date                          Signature of Parent/Guardian                                     Signature of Child Care Provider