SUMMER BREEZE CHILD CARE LTD.

REGISTRATION FORM

______DATE ENROLLED SCHOOL:______AGE:______

NAME OF CHILD

SURNAMEGIVENMIDDLE NAME

CHILDS ADDRESSPostal Code

SEX  M  FMonth ______Day ______Year______FIRST DAY OF ATTENDANCE / /

PARENT/GUARDIAN

NAMECELL PHONE

PLACE OF WORKPHONE

HOME ADDRESSPHONEHOURS OF WORK

NAMECELL PHONE

PLACE OF WORKPHONE

HOME ADDRESSPHONEHOURS OF WORK

MEDICAL INFORMATION

FAMILY DOCTORPHONE

MEDICAL INSURANCE PLAN NUMBER

ALTERNATE PERSON TO CALL/PICK-UP CHILD IN CASE OF EMERGENCY

NAMERELATIONSHIP PHONE

NAMERELATIONSHIPPHONE

PERSONS (OTHER THAN PARENT/GUARDIAN, AND EMERGENCY CONTACTS) AUTHORIZED TO PICK UP CHILD FROM FACILITY

NAMEPHONE

NAMEPHONE

NAMEPHONE

OTHER CHILDREN LIVING AT HOME

NAMEDATE OF BIRTH / /

Y M D

NAME DATE OF BIRTH / /

Y M D

HAS CHILD HAD PREVIOUS EXPERIENCE AWAY FROM HOME?

(DAY CARE, PRESCHOOL, SUNDAY SCHOOL, ETC.) YES  NO

Does your child Have any special Toileting Needs:  Yes  No

IF CHILD HAS ANY KNOWN HEALTH PROBLEMS, INDICATE WHAT THEY ARE:

Does your child have a Support Worker?  Yes  No

COMMENTS OR INSTRUCTIONS FOR CAREGIVER (TICK APPROPRIATE ONES):

 MEDICATION (Please fill out Authorization to Administer Medication Form

 ALLERGIES Does this allergy require an Epi Pen  Yes No

THERAPEUTIC DIET (FOR REASONS OF HEALTH, RELIGION, ETHNICITY): ______

SPECIAL INSTRUCTIONS FROM PARENT OR HEALTH CARE PROFESSIONAL: (ATTACH DOCUMENTATION)

 CUSTODY ORDERS  YES  NO (ATTACH DOCUMENTATION)

INDICATE ANY ILLNESS OR MEDICAL DISABILITIES YOUR CHILD HAS (GIVE DATES):

BASIC IMMUNIZATION SCHEDULE – IS YOUR CHILD IMMUNIZED? YES  NO 

1ST visit
@2 mo. / 2ND visit
2 mo. After
1st / 3RD visit 2 mo. After 2nd / 4TH visit 12 mo. of age / 5TH visit
12 mo. after 3rd / 4 – 6 YEARS / GRADE
6 / GRADE 9 / GRADE 12
Indicate Date Immunizations Received
Diphtheria / * / * / * / * / * / *
Pertussis / * / * / * / * / * / *
Tetanus / * / * / * / * / * / *
Poliomyelitis / * / * / * / * / *
HIB (1) / * / * / * / *
Hepatitis B / *(2) / *(2) / *(2) / ** (3)
Pneumococcal Conjugate / *(4) / *(4) / *(4) / *(4)
Measles/Mumps/Rubella / * / *
Meningococcal C Conjugate / *(5) / *(5) / *(7) / *(7) / *(7)
Varicella (Chickenpox) / *(8) / *(9) / *(9)
  1. HIB protects against Haemophilus influenza B which may cause meningitis.
  2. Hepatitis B immunization program for children born on or after January 1, 2001.
  3. Grade 6 Hepatitis B for children who were not previously immunized.
  4. Pneumococcal Conjugate for children born on or after July 1, 2003.
  5. Meningococcal C Conjugate:
    - for children born on or after April 1, 2005 one dose at 2 months of age and one dose at 1 year of age
    - for children born on or after July 1, 2002 one dose at 12 months
  6. All First Nations children, ages 2-59 months, should receive an age-appropriate series of Pneumococcal Congugate vaccine
  7. Grade 6 and Grade 9 Meningococcal C:
    - for children who were not previously immunized.
  8. Varicella (Chickenpox) for children, born on or after January 1, 2004, who have not had chickenpox disease, shingles, or previous dose of Varicella vaccine.
  9. Varicella (Chickenpox) for children who have not had chickenpox disease, shingles or previous dose of Varicella vaccine.

I HEREBY GIVE MY CONSENT FOR A STAFF MEMBER TO CALL A MEDICAL PRACTITIONER OR AMBULANCE FOR MY CHILD IN THE CASE OF ACCIDENT OR ILLNESS, IF I CANNOT IMMEDIATELY BY REACHED.

PARENT’S SIGNATUREDATE

Summer Breeze Child Care Ltd.

Medical Permissions and Authorizations

I ______legal parent/guardian of the child______

I acknowledge and agree to the following: (Please Initial)

 My child Is Immunized  Yes  No If Yes. My child’s Immunizations are up to dateYes  No

 I have chosen not to immunize my Child. If no please initial the statement below.

 I understand that should there be an outbreak or suspected outbreak of any communicable disease, I will have to remove my child from the Centre until cleared in writing by a medical staff.

 I would like Summer Breeze Child Care to NOT call me for every first aid incident that my child is involved in. I would like to be called ONLY in a FIRST AID EMERGENCY (i.e. Child requires medical attention at clinic or hospital, head injury, or has a communicable disease)

 To be transported by ambulance (at parents cost) to the nearest medical facility with a member of Summer Breeze Child Care Staff in the event of an accident/illness Yes  No 

 I understand that all parents will be notified first if possible  Yes  No

I authorize Summer Breeze Staff to apply sunscreen if and when deemed necessary yes  No

______

Signature of Parent/GuardianDate

Transportation and Photography Authorization

I______give my permission for staff of Summer Breeze

Child Care Ltd. to transport my child ______, for the following :( Please Initial)

 All Field trips arranged by Summer Breeze Child Care Staff or Management.

 To be transported in a Summer Breeze Child Care Vehicle or Staff vehicle to and from field trips, outings, and when applicable to and from school. I understand that all safety precautions will be taken at all times by the staff at Summer Breeze Child Care Ltd.

 I agree to have my child’s photograph taken in the program setting for general record keeping and publicity purposes Yes No

______, ______

Signature of Parent/Guardian Date

Policy and Procedure Handbook

I ______legal parent/guardian of the child ______have read and understand the policy and procedure Handbook provided by Summer Breeze Child Care that I received with this registration form. I am aware and agree to abide by the following Centre policies regarding :( Please initial the following)

 Post-Dated cheques dated for the 1st of each month for the month of care

 If MCFD or child care subsidy is paying a fees or a portion of fees, I agree to pay the full amount until Fees are paid by the Organization. Parent Portion fees will be post-dated

 I understand priority will be given to full time enrollment

 $25 NSF fee will be charged on each N.S.F cheque

 If payment is not received on time, I understand my child may lose his/her space

 One month’s written notice is required when withdrawing your child from the program

 Authorization for us to contact you via email at the email address provided.

I accept all responsibility for payment on all accounts rendered to my family  Yes No

______

Name of Parent/Guardian Date

Thank you for Choosing Summer Breeze Child Care Ltd.

Family Personal Information Sheet For Quick Access: Child’s Name______

Time of Drop Off ______AM Time of Pick up ______PM Days Attending: M T W Th Fr

Parent/ Guardian______Contact Cell Number______

Parent/Guardian______Contact Cell Number______

Custody orders  Yes  No Copies on File with Centre  Yes  No

Parents Email______

Parents Email______

Alternate Email______

Sibling’s ______

Alternate Persons to Pick Up

Name______Cell Phone______Relation______

Name______Cell Phone ______Relation______

Allergies:______

Epi Pen______Care Plan On File Yes  No

Child’s School ______Child’s Teacher______

School Phone Number______Grade:______

Food Dislikes ______

Childs Favorite Toy/ or Comfort Item______

What makes your child feel better when they are upset? ______

Any Special Holidays your Family Celebrates? ______

Is English your First Language?  Yes  No If No What is your first Language______

Any Holidays or Celebrations you wish your child Not to Participate ______

Any Other Information you would like the Centre to know about your Family and Child that would better help us to know you and meet your Childs Needs.______

______