Summerland Christian Playschool 2022-23
Registration for September 21, 2022 to June 16, 2023.
Child's Full Name
*
First Name
Last Name
Child's Gender
*
Male
Female
Child's Birthdate
*
-
Month
-
Day
Year
Date
Name of Mother
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Father
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Guardian
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Child Lives With
*
Both Parents
Father
Mother
Other
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Emergency Contact #1 (must be someone other than a parent)
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
*
Name of Emergency Contact #2 (must someone other than a parent)
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
*
Care Card Number
*
Physician's Name
*
Physician's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you give Summerland Christian Playschool permission to call Physician/Ambulance in the case of an emergency?
*
Yes
No
Has your child been immunized?
*
Yes
No
First DPTP/HIB
-
Month
-
Day
Year
Date
Second DPTB/HIB
-
Month
-
Day
Year
Date
Third DPTB/HIB
-
Month
-
Day
Year
Date
Fourth DPTB/HIB
-
Month
-
Day
Year
Date
First MMR
-
Month
-
Day
Year
Date
First HEP B
*
-
Month
-
Day
Year
Date
Second HEP B
-
Month
-
Day
Year
Date
Third HEP B
-
Month
-
Day
Year
Date
Does your child have any medical conditions?
*
Yes
No
Does your child have any allergies?
*
Yes
No
Please give details for any conditions checked 'Yes' above
Is your child on any medications?
*
Yes
No
Does your child have any vision, hearing, or communication concerns?
*
Yes
No
Does your child have any learning or physical concerns?
*
Yes
No
Does your child have any behavior or emotional concerns?
*
Yes
No
Does your child have a special diet?
*
Yes
No
Have there been any significant changes in your child's life? (eg. death, separation, move, new sibling?)
*
Yes
No
I will make every effort to be prompt for drop-off and pick up times.
*
I Agree
I Disagree
In the event of absenteeism due to illness, vacation etc. (not initiated by the playschool staff), I understand that I am still responsible for full payment, unless otherwise arranged as noted below.
*
I Agree
I Disagree
I will not send my child to the playschool if there is illness and I will notify the playschool staff if my child has come into contact with a communicable disease.
*
I Agree
I Disagree
In case of accident or illness, I authorize the playschool staff to contact a physician and/or ambulance. I accept responsibility for payment of ambulance fees.
*
I Agree
I Disagree
In the case of playschool staff emergency, I authorize a substitute staff person to care for my child.
*
I Agree
I Disagree
I have received a copy of the Parent Handbook. I have read and agree to all of the policies provided therein.
*
I Agree
I Disagree
I give permission for my child to participate in all field trips and activities that may be held on or off site.
*
I Agree
I Disagree
Please be aware that all playschool facilities and registration information is open to visits from the local health centre staff such as: licensing officers, public health nurses. These visits are for monitoring and information.
*
I Agree
I Disagree
Do you give permission for the reasonable use of pictures and/or video containing your child on our SBC website or related social media sites?
*
I Give Permission
I Do Not Give Permission
How would you like to pay?
*
Please Select
Tithe.ly (credit card)
Cheque(s)
I understand that for my registration to be complete, either postdated cheques must be handed in to the SBC office OR a Recurring Payment Schedule must have been set up in Tithe.ly (simple instructions are in the Parent Handbook).
*
Yes, I Understand
No, I Do Not Understand
By selecting the "I Accept" button below, you are signing this Agreement electronically and you agree your electronic signature is the legal equivalent of your manual signature on this Agreement. If you select 'I Do Not Accept' we will require you to print and sign this document and bring it in to the Playschool Director before your application can be completed. This applies to the school year running from September 20, 2021 to June 8, 2022.
*
I Accept
I Do Not Accept
Name of parent/person filling out this form:
*
Submit
Should be Empty: