Online Registration Form

Please come into the centre to register your child. We would like to meet you and your child. Im sure you would like to meet us!

Starting date

Termination

Full Name of Child

Name Child is called at home

Date of Birth

Place of Birth

Address

Postal Code

Phone

Mother Tongue

Second Language

Parents/Guardians

Father Details

Name

Address

Work Address

Occupation

Phone

Cell Number

Mother Details

Name

Address

Work Address

Occupation

Phone

Cell Number

Sibling(s) (please indicate ages)

Name

Age

Name

Age

Emergency Contact Person

Name

Address

Phone

Parent/Guardian Driver’s License #

Parent Alberta Health Care #

Medical Information

Child’s Doctor’s Name

In the last year, has your child had any difficulty with the following ?

Earaches YesNo

Hearing YesNo

Eating YesNo

Bowels YesNo

Fever YesNo

Speech YesNo

Vision YesNo

Sleeping YesNo

Urinary accidents YesNo

Making friends YesNo

Is you child developing as you think he/she should for his (her) age ?
(e.g. Toilet trained? Talking?

Has your child had any medical or emotional condition requiring or
receiving treatment?

Is your child on daily medication ?

Has your child had any of the following?

RubellaEpilepsyChicken poxMeaslesPoisoningConvulsionsMumpsHead injuryHeart conditionSurgeryWhooping coughTuberculosisAsthmaDiabetesJaundice

Please List any known allergies,

Please provide the dates of the child’s immunization for the vaccines listed.

Diphtheria

Whooping

Cough

Tetanus

Polio

Measles

Mumps

Rubella

Please list here, any information concerning your child’s health that has not been
covered

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