Registration Form

Step 1 of 3

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Child Information

Child's Name:

First Last

Child's Date of Birth(Required)

Month

Day

Year

Gender:(Required)

Male

Female

Prefer not to say

Sibling Names(Required)

First

Dietary restrictions(Required)

None

Vegetarian

Vegan

Kosher

Gluten-free

Other

Parent/Guardian 1 Information

Relationship to Child (Eg. Mother, Father, etc.)(Required)

Parent Name:(Required)

First Last

Phone Number:(Required)

Alternate Phone Number

Work Phone Number

Parent Email Address(Required)

Address(Required)

Street Address City Province Postal Code

Parent/Guardian 2 Information

Relationship to Child (Eg. Mother, Father, etc.)

Parent Name:

First Last

Phone Number:

Alternate Phone Number

Work Phone Number

Parent Email Address

Address

Street Address City Province Postal Code

Emergency Contacts/Authorized to Pick Up

Emergency Contact 1 Name:(Required)

Relationship to Child:(Required)

Emergency Contact 1 Phone Number:(Required)

Emergency Contact 2 Name

Relationship to Child

Emergency Contact 2 Phone Number

Custody

Are there any custody or visitation arrangements that staff at Anderdon Child Care should be aware of?(Required)

Yes

Please explain(Required)

Health Information

Does the child have any allergies?(Required)

Yes

Untitled(Required)

Does the child require an EPI-pen?(Required)

Yes

Is the child diabetic?(Required)

Yes. I will contact the site Supervisor to discuss a plan of care.

Is the child epileptic?(Required)

Yes. I will contact the site Supervisor to discuss a plan of care.

Please list any other pertinent health information for the child here:

Health Card Number:(Required)

Child's Doctor:(Required)

Child's Doctor's Phone Number:(Required)

Are there any other health care professionals currently working with your child that we should be aware of? Eg. Children's First, Physiotherapist, John McGivney Centre, Community Living, etc. If so, please list them here.

I am providing my consent for my child to use all of the equipment provided by Anderdon Child Care and participate in alI activities conducted by child care staff on the property of Anderdon Public school. Should there be a medical emergency, I grant the Supervisor or acting Supervisor permission to take whatever steps necessary to obtain Emergency medical care if warranted. These steps may include but are not limited to the following: Attempt to contact parent/guardian and contact any of the emergency contacts listed on this form. In addition to calling the child's guardian we will, if required 1) Call an Ambulance 2) Transport child to hospital by a licensed staff member. Any of the expenses incurred by following the steps above will be the responsibility of the child's family.(Required)

Yes

Policy Acknowledgements

Workplace Harassment

Health and safety of our clients and employees is our top priority. We are committed to protecting our employees and our clients from harassment and discrimination. Such conduct interferes with everyone’s ability to perform their job and is not in keeping with our vision. By working together, and giving attention to the safety and well being of all those in our centre, we will meet maintain a healthier and safer working environment for all. Our employees, clients and parents are entitled to be treated with dignity and respect and have a work environment free from harassment and discrimination. This policy applies to all employees, clients, parents while at the centre, during work related field trips or travel, or through any electronic communication. Examples of behaviour that will not be tolerated: intimidation, insulting remarks directed at staff, loud or aggressive remarks directed at staff. We will not tolerate any form of Workplace harassment and all incidents will be dealt with and are not limited to the examples above. Complaints from staff regarding parents/guardians will be dealt with immediately and termination of care and/or disciplinary action will take effect when appropriate. *

Yes, I have read the workplace harassment policy and agree to the terms and conditions listed here. I understand that any violation of this policy may be grounds for removal from ACC. Your answer will be saved.

Consent To Photograph

I consent to the use of photographs/images of the child registered with this form in any social media, website and/or print materials created or maintained by Anderdon Child Care. This includes but is not limited to future promotional material, Facebook, websites, etc.(Required)

Yes

Consent to Sunscreen Application

I consent to Anderdon Child Care staff applying and re-applyng sunscreen (Minimum SPF of 30) before going outside for any length of time. Parents should provide a bottle of sunscreen clearly labelled with the child's name. In the event that sunscreen is not provided, expires or runs out, I consent to child care staff using/applying sunscreen provided by Anderdon Child Care. *(Required)

Yes

I understand that I may supply the following items; insect repellant, lip balm, hand sanitizer, moisturizing hand lotion, and/or soap for my child to use while at Anderdon Child Care. I understand that all products must be in their original containers clearly labelled with the child's name. I grant permission for Anderdon Child Care staff to apply any of the above items that I have supplied. We will not administer or allow your child to administer any product that has expired or has an expiry date that is not legible. Products must be administered in accordance with the directions on their original container. I understand the purpose of these non-medication products and hereby release Anderdon Child Care and their staff from any liability in the application of these products.(Required)

Yes

Termination of Service

Should a child experience difficulty in adapting to the ACC's environment or adhering to the daycare rules of behavior, a meeting will be scheduled and ACC staff will work closely with you to see if the problem can be resolved. If the child's behaviour continues to be disruptive to the group, we reserve the right to ask you to withdraw your child from Anderdon Child Care. You will be notified of any incidents involving the child and will be required to sign a detailed report. Each child's situation is different and the severity of the incidents will be considered befoe making a decision to remove a child from our program. If the rules and policies of the centre are not followed, we reserve the right to terminate the child care contract agreement at any time. Child care arrangements may be terminated for any of the following reasons (but not limited to): a) Failure to comply with the contract. b) Destructive or hurtful behaviour of a child or staff member that persists even after consultation with parent c) Use of inappropriate language d) Inability to meet the child's needs without additional staff e) repeated disrespect towards staff f) Non-payment of fees.

Yes, I have read the termination policy and agree to the terms and conditions listed here. I understand that any violation of this policy may be grounds for removal from our program. Your answer will be saved.

Additionally, I agree to: 1) Pay for the month's tuition, in advance, at the beginning of each month unless an alternate agreement is made with Supervisor (eg. October payment due Oct 1st) 5 days grace will be given. 2) I will provide the Supervisor with a child care Schedule before the start of the month 3) I will inform my child's school teacher of the child care schedule also. I understand that this document serves as a child care contract.

Yes, I agree

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Registration Form

Child Information

Parent/Guardian 1 Information

Parent/Guardian 2 Information

Emergency Contacts/Authorized to Pick Up

Custody

Health Information

Policy Acknowledgements

Consent To Photograph

Consent to Sunscreen Application

Termination of Service

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