Little Me Registration

Child's Information

First name

Last name

Date of Birth

Gender

Program Type (please select one)

Days of the week required

Child 2's Information (if registering siblings)

First name

Date of Birth

Last name

Gender

Program Type (please select one)

Days of the week required

Street address

Street address line 2

City

Province

Country

Postal Code

Start Date

Parent/Guardian Information

Parent's/Guardian's name

Relationship to Child

Home Phone number

Cell Phone number

Work Phone number

Place of work

Email address

example@example.com

Parent/Guardian Information

Parent's/Guardian's name

Relationship to Child

Home Phone number

Cell Phone number

Work Phone number

Place of work

Email address

example@example.com

Total Family Income according to 2025 Assessment

Emergency Contact 1
In the event of an emergency, please contact:

First name

Last name

Relationship to Child

Home Phone Number

Cell Phone Number

Emergency Contact 2
In the event of an emergency, please contact:

First name

Last name

Relationship to Child

Home Phone Number

Cell Phone Number

Emergency Contact 3
In the event of an emergency, please contact:

First name

Last name

Relationship to Child

Home Phone Number

Cell Phone Number

List all the people AUTHORIZED to pick up your child from school (name and relationship to the child- includes parents and emergency contacts).

Family Physician's Name

Family Physician's Phone Number

Child's Healthcare Number

Does your child have a history of serious illness?

If yes, please explain.

Does your child have any allergies?

If yes, please explain.

Is your child fully immunized?

Does your child have any medical, emotional or behavioral conditions or special needs that requires special treatment or supervision?

If yes, please explain.

Is your child currently taking any medication?

If yes, please explain.

What Language is Spoken at Home?

What Language does your child understand?

What activities does your child enjoy most?

What activities does your child enjoy least?

Does your child have any special interests?

Does your child have any fears or phobias?

Any Other Comments or Concerns

Do you or anybody you know have a job, talent, or experience that you (or he/she) would like to share with your child's class? If so, please describe below.

Do you consent to allow Little Me to take photos of your child to be displayed at the program site to be shared with the class, parents, and to create memories as part of the curriculum only?

Do you consent to allow Little Me to add your email address to their email list to send the monthly newsletter, any class reminders that concern your child and any information regarding activities within the centre? Your email address will be protected by the company's Privacy Policy and will not be distributed outside the Centre.

This registration will need to be updated by the parents / guardians on an annual basis to ensure all the information within is as accurate as possible.I / We certify that all the information provided in this registration form is accurate and true to the best of my / our knowledge. I / We agree to notify the Program immediately should anything change.

Signature

Full Name

Date

Fees (must be paid at the time of registration)

Registration Fee

$125.00 CAD

Total

Payment Methods

Credit Card

Apple Pay

Google Pay

REGISTRATION FORM

Medical Information

Other Information

Program Questions

Parent/Guardian Signatures

Fees (must be paid at the time of registration)

Payment Methods

REGISTRATION FORM

Medical Information

Other Information

Program Questions

Parent/Guardian Signatures

Fees (must be paid at the time of registration)*

Payment Methods

Fees (must be paid at the time of registration)