La petite ecole Registration Form

La petite ecole

REGISTRATION FORM
GENERAL INFORMATION
Name of Child*

First NameLast Name
Sex of Child*
Child's Starting Date at La petite ecole*

MonthDayYear
Personal Health Number*
Child's Birthday*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Parent/Guardian*

First NameLast Name
Email*
example@example.com
Mobile/Cell number*
Please enter a valid phone number.
Alternative Number
If you do not have a home phone, please leave this blank.
Parent/Guardian*

First NameLast Name
Email*
example@example.com
Mobile/Cell number*
Please enter a valid phone number.
Alternative Number
If you do not have a home phone, please leave this blank.
Please indicate any person with whom your child lives other than their parent/s (ie. Rosalie: sister/Grandmother: Nana).*
Please list any other preschools and/or regular weekly activities with days and times in which your child is enrolled.*
If there is a custody agreement for this child in which we need to be aware, please provide more detail below.
PERSONS AUTHORIZED FOR PICK UP*

*You must include any parent/guardian listed above as well as another person besides a parent/guardian.
Name of authorized person to pick up.*

Full name of personRelationship to child
Phone Number*
Name of authorized person to pick up*

Full name of personRelationship to child
Phone Number*
Name of authorized person to pick up*

Full name of personRelationship to child
Phone Number*
Name of authorized person to pick up*

Full name of personRelationship to child
Phone Number*
Name of authorized person to pick up

Full name of personRelationship to child
Phone Number
Name of authorized person to pick up

Full name of personRelationship to child
Phone Number
MEDICAL INFORMATION
Does your child have a medical condition. If yes, please provide more detail below.*

YESNO
Does your child have allergies? If yes, please provide more detail below. We may ask you to fill in additional documents if necessary.*

YESNO
Does your child have asthma? If yes, please provide more detail below.*

YESNO
Has your child had a seizure in the last year? If yes, please provide more detail below.*

YESNO
Please let us know if there are any over the counter medications your child takes on a daily basis and when they are taken.
IMMUNIZATION INFORMATION
What is the status of your child's immunization*
Please provide more details of your child's immunization status, if necessary. It is no longer required to submit your record of immunization.
PHOTO CONSENT
I give permission to teachers at La petite ecole to have my child's photo used on Instagram or La petite ecole website.*
OUTSIDE CONSENT
I give permission to teachers at La petite ecole to take my child outside of the school grounds (ie. forest, park, library).
Name of Parent/Guardian*

First NameLast Name
Signature of Parent/Guardian*

Clear
WAIVER & RELEASE OF RESPONSIBILITY
I hereby assume all risk of personal injury for all the years my child attends or participates in La petite ecole activities, including, but not limited to, playground activities, classroom activities, as well as field trips taken in connection with La petite ecole.
Name of Parent/Guardian*

First NameLast Name
Signature of Parent/Guardian*

Clear

La petite ecole

GENERAL INFORMATION

PERSONS AUTHORIZED FOR PICK UP*

MEDICAL INFORMATION

IMMUNIZATION INFORMATION

PHOTO CONSENT

OUTSIDE CONSENT

WAIVER & RELEASE OF RESPONSIBILITY

EMERGENCY CONSENT FORM