Leapin' Lizards Registration

Registration

Leapin' Lizards Daycares Inc., Penticton BC
Requested Enrolment Date *

Month Day Year
Date
Withdrawl Date (Office Use Only)

Month Day Year
Date

CHILD'S INFORMATION
Child's Name *

First Name Last Name
Middle Name, if applicable
Child's Birth Date *

Month Day Year
Date
Male or female? *

Female Male

PARENT/GUARDIAN INFORMATION
Name of Parent/Guardian #1 *

First Name Last Name
Main Phone Number *
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Place of work
Work Ext.
Email address *
example@example.com
Name of Parent/Guardian #2

First Name Last Name
Main Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Place of work
Work Ext.
Email address
example@example.com
Physical Address *

Street Address

Street Address Line 2

City Province

Postal
Mailing Address (if different physical address)

Street Address

Street Address Line 2

City Province

Postal

CHILDCARE NEEDS

Leapin' Lizards has 3 Locations in Penticton, BC!
Requested Childcare Centre *
Childcare Required (select all that apply) *

Full-time Before & After School Part-time Before & After School School Break Childcare (Winter/Spring) Drop-in Pro-D Day Childcare Summer Childcare

EMERGENCY CONTACTS

Persons to contact in case of emergency (OTHER than parents or guardians)
Emergency Contact #1 *

First Name Last Name
Relationship *
Main Phone Number *
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Emergency Contact #2 *

First Name Last Name
Relationship *
Main Phone Number *
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.

AUTHORIZED PERSONS

The following people are AUTHORIZED to pick up my child:
Authorized Person #1 *

First Name Last Name
Relationship *
Main Phone Number *
Please enter a valid phone number.
Authorized Person #2

First Name Last Name
Relationship
Main Phone Number
Please enter a valid phone number.
Authorized Person #3

First Name Last Name
Relationship
Main Phone Number
Please enter a valid phone number.
Authorized Person #4

First Name Last Name
Relationship
Main Phone Number
Please enter a valid phone number.

UNAUTHORIZED PERSONS

The following people are NOT AUTHORIZED to have access to my child:
UNAUTHORIZED Person #1

First Name Last Name
Relationship
Main Phone Number
Please enter a valid phone number.
UNAUTHORIZED Person #2

First Name Last Name
Relationship
Main Phone Number
Please enter a valid phone number.
UNAUTHORIZED Person #3

First Name Last Name
Relationship
Main Phone Number
Please enter a valid phone number.
UNAUTHORIZED Person #4

First Name Last Name
Relationship
Main Phone Number
Please enter a valid phone number.

MEDICAL INFORMATION
Doctor's Name *

First Name Last Name
Doctor's Phone Number *
Please enter a valid phone number.
Dentist's Name *

First Name Last Name
Dentist's Phone Number *
Please enter a valid phone number.
Immunization Status *
Medical Services Plan Number (MSP) *

Description of Child:
Height *
Weight *
Hair Colour *
Eye Colour *
Please upload current colour photograph of your child: *

Cancel of
Does your child have any distinguishing features? If yes, please describe:
Ex. Mole on left cheek, birthmark on right forearm.

Significant changes in your child’s life?
Ex. death, separation, move, new sibling
Special instructions about food likes and dislikes, nap time, toilet, favourite things, fears, religious and/or cultural observances, etc.

CUSTODY / GUARDIANSHIP INFORMATION

Court Orders or Restraining Orders
Is there a custody agreement or restraining order? *

Yes No
If yes, a copy must be provided. File Upload:

Cancel of

I understand that the Caregiver or Manager must report any accident or incident of a suspicious nature. *

Yes
I have read and agree to the information provided to me in the Parent Handbook and will notify the Leapin' Lizards Caregiver or Manager if there are any changes. *

Yes
Signature, Parent/Guardian #1 *

Clear
Date *

Month Day Year
Date
Signature, Parent/Guardian #2

Clear
Date

Month Day Year
Date

PARENT/GUARDIAN CONTRACT
- Flat monthly rates are averaged out over the year based on daily rate
- Early dismissal days will be billed extra for those requiring the service
- Direct deposit or post-dated cheques are required
- Leapin' Lizards will be open and offer full-day childcare services during BC Teacher’s Job-Action Strikes and unforeseen school closures
KINDERGARTEN FEES

Full-time (5days/week) = $330 /month

Part-time (3 days/week) = $250 /month

Spring Break & Pro-D Days = $30 /day

Drop-in = $17 /day

Late Pick-up Fee $10 /every 5 minutes
GRADES 1 - 5 FEES

Full-time (5 days/week) = $260 /month

Part-time (3 days/week) = $160 /month

Spring Break & Pro-D Days = $30 /day

Drop-in = $15 /day

Late Pick-up Fee $10 /every 5 minutes
I have received and agree to the Leapin' Lizards fee schedule, I acknowledge that fees are charged monthly in-advance. (Unless alternate payment arrangement is agreed upon by both the Parent/Guardian and the Caregiver) *

Yes
Alternate payment arrangements?
Ex. Bi-weekly in-advance, weekly in-advance
I understand that fees do not include breakfast, lunch, dinner, snacks, transportation, special diet, or special activities. *

Yes

SCHEDULE	SCHOOL DAY AM	SCHOOL DAY PM
COLUMBIA	7:00 am - Bell	Bell - 5:30 pm
PARKWAY	7:00 am - Bell	Bell - 5:30 pm
WEST BENCH	7:30 am - 8:50 am	2:45 pm - 5:30 pm

I will make every effort to be prompt in bringing my child to Leapin' Lizards at: *
Ex. 7:30 am or not applicable.
I will make every effort to be prompt in picking my child to Leapin' Lizards at: *
Ex. 5:30 pm or not applicable
I agree that any time over and above the agreed hours of care, will be charged as overtime at the rate of $10 per every 5 minutes. *

Yes
I agree that in the event of absenteeism due to illness, vacation, etc., NOT initiated by the Caregiver, I understand I am still responsible for full payment. (unless otherwise arranged as noted below) *

Yes
Notes:
I will not send my child to Leapin’ Lizards if they are ill and I will notify the Caregiver if my child has come in contact with a communicable disease. *

Yes
In the case of accident or illness I authorize facility staff to contact a physician and/or ambulance. I accept responsibility for payment of ambulance fees. *

Yes
In case of caregiver emergency I authorize a substitute caregiver to care for my child. *

Yes
I have received a copy of the Leapin’ Lizards Parent Handbook. I have read and agree to all of the policies as provided to me. *

Yes

PARENT/GUARDIAN CONTRACT
I give permission for my child to participate in spontaneous WALKING trips with the caregiver. (For any other spontaneous or planned field trips, a separate consent is required) *

Yes No
I give permission for my child to participate in spontaneous CAR trips with the caregiver. (For any other spontaneous or planned field trips, a separate consent is required) *

Yes No
I give permission for my child’s photograph to be taken and possibly used for general advertising of Leapin’ Lizards. *

Yes No

PARENT/GUARDIAN CONTRACT
REFUND AGREEMENT & WITHDRAWL NOTICE
- Payment of childcare fees are due in advance at the beginning of each month
- Parents receiving childcare subsidy must have an authorization number before childcare will be provided
- Fees over and above the subsidy portion are the responsibility of the parent to pay on time
- Drop-in fees are payable on the day of drop-in childcare is provided. Unless a pre-arrangement has been made with management
- Payment is required in full, regardless of absent days due to illness, vacation or other
- Unless otherwise agreed - 30 days notice in writing is required by parents who wish to terminate the contract. All post dated cheques will be returned at the date of withdrawal
- The management of Leapin' Lizards has the right to terminate the contract due to continual behaviour issues of a child. Extenuating circumstances will be considered
- Refund may be provided if withdrawal is in the best interest of the child and the decision has been mutually agreed upon by all parties at the discretion of the Manager
- If childcare is interrupted by unforeseen circumstances (fire, earthquake, or school strike closure) an appropriate alternative venue will be sought. If no other venue has been secured, reimbursement will be made as soon as conveniently possible
- All post dated cheques will be returned at the date of withdrawal and refunds will be made by cheque to be either picked up or mailed to parents home address
- Leapin' Lizards offers Direct Deposit for childcare payments. Upon notice being given that a child is not going to be attending, direct deposit will be immediately removed
Signature By initialing, I confirm receipt of the Leapin' Lizards refund agreement.
It is the responsibility of both the Caregiver and the enrolled child’s parents to let each another know if the child seems unhappy or that the arrangement is unsatisfactory for any reason.
I am aware that ALL Childcare Facilities and registration information is open to visits from the Local Health Centre Staff such as: Licensing Officers and Public Health Nurses. These visits are for information and support. *

Yes
I understand that this contract can be terminated by either party during the adjustment period of two (2) weeks. After this adjustment period, termination of Childcare services requires thirty (30) days notice by either party in writing. *

Yes
I have read and agree to the above information and will notify the Caregiver if there are any changes. *

Yes
Signature, Parent/Guardian #1 *

Clear
Date *

Month Day Year
Date
Signature, Parent/Guardian #2

Clear
Date

Month Day Year
Date
Signature, Caregiver/Manager (office use only)

Clear
Date

Month Day Year
Date
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Registration

CHILD'S INFORMATION

PARENT/GUARDIAN INFORMATION

CHILDCARE NEEDS

EMERGENCY CONTACTS

AUTHORIZED PERSONS

UNAUTHORIZED PERSONS

MEDICAL INFORMATION

CUSTODY / GUARDIANSHIP INFORMATION

PARENT/GUARDIAN CONTRACT

PARENT/GUARDIAN CONTRACT

PARENT/GUARDIAN CONTRACT