Little Me Registration

Child's Information

First name*

Last name*

Date of Birth*

Gender*

MaleFemaleChoose not to mention

Program Type (please select one)*

Infant (0M-19M)Junior Preschool (19M-3Y)Pre-K (3Y-4Y)Junior Kindergarten (4Y-5Y)

Days of the week required*

Tuesday, ThursdayMonday, Tuesday, Wednesday, Thursday, Friday,

Do you require before or after school care?*

Before CareAfter CareNone

Child 2's Information (if registering siblings)

First name

Date of Birth

Last name

Gender

MaleFemaleChoose not to mention

Program Type (please select one)

Infant (0M-19M)Junior Preschool (19M-3Y)Pre-K (3Y-4Y)Junior Kindergarten (4Y-5Y)

Days of the week required

Tuesday, ThursdayMonday, Tuesday, Wednesday, Thursday, Friday,

Do you require before or after school care?

Before CareAfter CareNone

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 2023 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?*

YesNo

If yes, please explain.

Does your child have any allergies?*

YesNo

If yes, please explain.

Is your child fully immunized?*

YesNo

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

YesNo

If yes, please explain.

Is your child currently taking any medication?*

YesNo

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?

YesNo

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.

YesNo

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

$125.00CAD

Total

$0.00CAD

Payment Methods

Credit Card

Apple Pay

Google Pay

REGISTRATION FORM

Medical Information

Other Information

Program Questions

Parent/Guardian Signatures

Payment Methods