2020/21 SCP Registration

Child Information
Name *

First Name Last Name
Gender *
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City Province

Postal Code
Class Selection

Options are: Monday & Wednesday Morning (3 Year Olds), Monday & Wednesday Morning (4 Year Olds), Monday & Wednesday Afternoon (4 Year Olds), Tuesday & Thursday Morning (3 Year Olds), Tuesday & Thursday Morning (4 Year Olds), Tuesday & Thursday Afternoon (4 Year Olds)
First Choice *
Second Choice
Third Choice
Friend Requests
We do our best to accommodate these requests, but cannot promise they will be honoured.

Child Information
I understand that my child needs to be fully potty trained to start preschool? *
Do you have any concerns regarding your child's development? (Check all that apply)

Attention Span Interaction with Others Speech Aggression
Is this child in foster care currently? *
Is there a documented Custody Arrangement for this child? *

Parent's Information
Mother's Information
Mother's Name

First Name Last Name
Mothers Phone Number

Area Code Phone Number
Mother's Employer
Mother's Work Phone Number

Area Code Phone Number
Father's Information
Father's Name

First Name Last Name
Father's Phone Number

Area Code Phone Number
Father's Employer
Father's Work Phone Number

Area Code Phone Number
Parent's Information
Email Address *
Used to communicate announcements and monthly calendars
Alternate Email Address
Optional
Marital Status *
Home Church
Parent Alternates
Parent Designate

Who may be contacted in the event of an emergency if BOTH parents are not available.
Name *
Phone Number *

Area Code Phone Number
Authorized Pick-Up List

Names of individuals to whom your child may be released for pick-up from Pre-School (other than parents)

Foster Care

Note: If you do not have these details readily available, you may submit them electronically later this week. This is required by the first day of class.
Name of Agency
Name of Social Worker
Office Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Office Email
example@example.com

Medical Consent

In the event that my child is ill or injured, and I cannot be reached, I give consent for the Steinbach Christian Preschool to refer my child to the family physician. if the physician cannot be reached, I give my consent to have my child taken to the Emergency Department of the hospital listed below
Hospital Name
Family Physician *
Physician Address *

Street Address

Street Address Line 2

City Province

Postal
Physician Phone Number *

Area Code Phone Number
Manitoba Health Family ID # (6 Digit) *
Manitoba Health Individual ID # (9 Digit) *
Child Allergies
In the event that my child is ill or injured, and I cannot be reached, by signing below, I give consent for the Steinbach Christian Preschool to refer my child to the family physician. if the physician cannot be reached, I give my consent to have my child taken to the Emergency Department of the hospital listed below
Parent Signature (Please use mouse to sign inside this box)

Clear
Social Worker Signature (if Applicable; Please use mouse to sign inside this box)

Clear

Medical Questionnaire

Please complete the following. Only select if the condition has been diagnosed by a medical professional
Medical Conditions *

Epipen/Auto-Injector Prescribed Epipen/Auto-Injector Provided to SCP Asthma Inhaler Provided to SCP Bleeding Disorder Diabetes Heart Condition Seizure Condition
Life Threatening Allergies? (please specify)
Other Significant Medical Conditions that are Physician Diagnosed
Does your child see a speech, occupational, or physical therapist? *
If yes, do you give us permission to contact the therapist? *
Contacting your child's therapist, allows us to provide the best possible preschool experience for your child? Y/N Who is your child's therapist?
Therapist's Name

First Name Last Name
Speciality/Type of Therapist
Therapist's Phone Number

Area Code Phone Number
The medical information is being collected so that an appropriate individual health care plan may be developed. The Steinbach Christian Preschool will share this above information with URIS (Unified Referral and Intake System) if your child has anaphylaxis or a severe medical condition. The program is a partnership between Health, Family Services and Housing, Education and Youth.

Parental Child Custody

Family Services requires SCP to have a copy of any court documentation regarding child custody. If this applies to your circumstances, please make sure the proper paperwork is attached. Note: If you do not have these details readily available, you may submit them electronically later this week. This is required by the first day of class.
Does this apply to your family? *
If yes, please upload copies of applicable documents:

Parental Consent

I have read and understand the information and procedure as outlined in the Parent Policy Statement
I have read and understand the information and procedure as outlined in the Parent Policy Statement *
Name of Individual Completing Form *

First Name Last Name
Relationship To Child: *

Once you click "submit", your form will be complete. Thank you for taking the time to complete this form. Once you hit submit, you will receive an e-mail at the e-mail address provided on the first page. Within this e-mail, you will receive instructions to complete your deposit to reserve your spot, if one is available.

Please complete this immediately.

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Child Information