Please complete this entire form. Incomplete forms will not be processed and
will be returned. (*) ARE REQUIRED FIELDS
Program (*)
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Please register my child for: (Days of attendance must be checked off)
Before-School
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After-School
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Infant/Toddler/Pre-School Room
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Parents must give 2 weeks notice in writing to change day(s) of care. You will be charged on the 1st and 15th of each month for booked days regardless if your child attends or not. Please consult your Parent Policy Manual for more details.
CHILD’S INFORMATION
Child’s Last Name: (*)
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Child’s First Name: (*)
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Date of Birth: (*)
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Month/Date/Year
Male or Female: (*)
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Child’s Address: (*)
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Home Telephone: (*)
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Town: (*)
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Postal Code: (*)
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MOTHER’S INFORMATION
Mother’s Last Name: (*)
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Mother’s First Name: (*)
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Address: (*)
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Home Telephone: (*)
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Employer: (*)
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Cell Phone:
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Work Phone:
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Email: (*)
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FATHER’S INFORMATION
Father's Last Name: (*)
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Father's First Name: (*)
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Address: (*)
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Home Telephone: (*)
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Employer: (*)
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Cell Phone:
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Work Phone:
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Email: (*)
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CUSTODY INFORMATION
Child currently lives with: (*)
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Other:
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If other from above please enter info here
Type of custody: (*)
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Other:
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If other from above please enter info here
IMPORTANT: If the current custody agreement is not included in the child’s file, we cannot deny access to either parent. A copy of the most current Court Order or Separation Agreement must be attached. It is the responsibility of the custodial parent to inform the Family Centre staff, in writing, of any changes, and to provide a copy of the amended Court Order immediately.
EMERGENCY CONTACTS:
(Please name two people we can call if parents cannot be reached)
Name: (*)
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Telephone Home: (*)
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Telephone Work: (*)
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Telephone Cell:
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Address: (*)
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Relationship: (*)
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Name: (*)
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Telephone Home: (*)
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Telephone Work: (*)
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Telephone Cell:
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Address: (*)
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Relationship: (*)
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AUTHORIZED PICK-UP PEOPLE:
(Please name anyone else, other that parents and emergency
contacts, who have permission to pick-up your child)
Name 1:
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Phone Number 1:
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Relationship 1:
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Name 2:
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Phone Number 2:
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Relationship 2:
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Name 3:
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Phone Number 3:
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Relationship 3:
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Name 4:
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Phone Number 4:
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Relationship 4:
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A parent/guardian's verbal authorization for pickup must be received before your child will be released to anyone not listed here. If we cannot contact you by phone, the child will not be released to other people not on the above list.
CHILD’S PERSONALITY & EXPERIENCES:
What are your child’s personality traits (i.e. shy, outgoing, fears)?
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What method of discipline do you use (i.e. time-out, 1-2-3, etc.)?
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Is there anything specific we need to know about your child?
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Has your child been in childcare programs before? Were there any difficulties? If so please provide
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CHILD’S SIBLINGS
Name 1:
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Age 1:
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School Attending 1
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Name 2:
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Age 2:
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School Attending 2
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Name 3:
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Age 3:
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School Attending 3
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Name 4:
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Age 4:
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School Attending 4
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CHILD’S MEDICAL INFORMATION
Family Doctor: (*)
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Telephone: (*)
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Health Card Number:
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Heath Card Number Expiry Date: (*)
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(*)
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Allergies/Reaction/ Treatment/Medication
(*)
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Illness or Medical Conditions/ Symptoms/ Treatment
IMMUNIZATION HISTORY
Please Provide the DATE for each - MONTH/DATE/YEAR - Required For each
Every flu season: (*)
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Flu: Influenza vaccine
To the best of my knowledge, my child’s immunization
Status is:
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Personal Exemption: I am opposed to immunization. I understand that my child can be excluded from attendance during an outbreak of a vaccine-preventable disease that he/she has not been immunized against, he/she may be excluded from all CAFRC programs until the outbreak is over.
Personal Exemption: (*)
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I am opposed to immunization - Please Check the BOX
PARENT AGREEMENT:
1. Health and Emergency Procedures: If your child should become ill at CAFRC programs, the staff will call you at the number on your registration form to come and pick him or her up. The staff will make the decision to call based on the best interest of both your child and the health of the other children in CAFRC programs. For this reason, it is important that your contact numbers are kept up to date. Should it become necessary to evacuate CAFRC programs, we advise you to tune into the local radio stations and listen for information concerning the evacuation. We will make every effort to contact you and notify as to our whereabouts, designated to us by Emergency officials ASAP. The above procedures are designed to keep parents informed and reduce concerns should unusual incidents occur.
2. Financial Obligation: : I understand and agree that I have to pay 2 weeks in advance of receiving CAFRC services. My account will be debited the 1st and 15th of each month. I agree that it is my responsibility to pay cash within 5 days of NSF charges or my child cannot attend any CAFRC programs. I also agree to pay any and all penalty fees (i.e. NSF fee, late pick-up fees, etc.), and that failure to do so will result in my child no longer being able to attend CAFRC programs and my overdue account will be sent immediately to Atlantic Collections Agency.
3. Parent Policy Manual: I have read the Parent Policy Manual and fully accept my responsibilities to the CAFRC.
4. Video and Photography Permission: I do hereby give permission for my child, to be photographed and/or video taped during program activities at the CAFRC. I understand that these photos may be used for display at CAFRC programs, or advertising in the newspaper or on our website.
5. Off-Site Permission: This form serves as blanket consent for all off-site outings in CAFRC programs. All trips are carefully organized and fully staffed. CAFRC is not responsible for children who arrive late for a pre-scheduled outing when prior, clear notification has been given.
6. Emergency Treatment Authorization: If your child becomes ill or has an accident while attending CAFRC programs, we will immediately inform you. If you are unavailable, we will contact your designated emergency contact. In the rare event that you or your designated contact is unavailable, and staff deems it necessary, your child will be transported to the nearest hospital emergency department. By signing below, I authorize CAFRC staff to approve of emergency treatment for my child that is recommended by medical personnel.
7. Liability Statement: I understand that every effort is made to ensure the safety and well-being of my child, and I release the Chester & Area Family Resource Centre, its employees, volunteers, and Board of Directors from liability. In consideration of acceptance into the program I/we, waive, release, and forever discharge the Chester & Area Family Resource Centre its employees, volunteers, and Board of Directors and their successors, all rights and claims from losses or damages due to any and all injuries suffered by my child while participating in CAFRC programs. I/we, hereby agree to reimburse the Chester & Area Family Resource Centre in the event my child should cause voluntary damage to CAFRC property and/or equipment.
Online Signature: (*)
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Registration Form