Admission / Registration Form

Child's Details

Date of Birth

Gender

First Name

Middle Name

Last Name

Religion/Culture Practiced at Home Language Spoken at Home Current Residential Address Preferred Choice of Name (if any) Seeking Admission For

Transportation Needs

Extended Care Needs

Start Time

End Time

First Parent / Guardian

Title

First Name

Middle Name

Last Name

Relationship to Child

Parental Responsibility

Home Telephone

Mobile Phone

Email Address

Work Telephone

Work Place

Second Parent / Guardian

Title

First Name

Middle Name

Last Name

Relationship to Child

Parental Responsibility

Home Telephone

Mobile Phone

Email Address

Work Telephone

Work Place

Other Children in Family

Supplementary Details

Previous Child Day-Care Programs / Schools Serious Illnesses or Injuries Immunization Completed Allergies / Medical Conditions Special Needs Potty Trained Fears Milk / Dairy Preferences Activities the Child Prefers Food the Child Enjoys Child Height Child Weight

Person Who May Pick Up Child

Declaration

I certify that all information above is true and correct. I acknowledge that money once paid is not refundable.

Parent / Guardian Name Date

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Admission / Registration Form

Child's Details

First Parent / Guardian

Second Parent / Guardian

Other Children in Family

Supplementary Details

Person Who May Pick Up Child

Declaration

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