Child's Information
PLEASE NOTE: To complete the form, your will be required to provide your Child's Doctor information and 2 Emergency Contacts (other than the primary caregiver).
Child's Name
*
First Name
Last Name
Child's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Sibling Names/Ages (if applicable)
Languages Spoken at Home
Custody Arrangements (if applicable)
Days Required for Care
*
Monday
Tuesday
Wednesday
Thursday
Friday
Start Date
*
-
Month
-
Day
Year
Date
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Parent/Guardian Information
Mothers Name
*
First Name
Last Name
Mothers Home Number
Please enter a valid phone number.
Mothers Cell Number
*
Please enter a valid phone number.
Mothers Email
*
Mothers Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Name
Employer Phone Number
Please enter a valid phone number.
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Father Information
Fathers Name
*
First Name
Last Name
Fathers Home Number
Please enter a valid phone number.
Fathers Cell Number
*
Please enter a valid phone number.
Fathers Email
example@example.com
Fathers Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Name
Employer Phone Number
Please enter a valid phone number.
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Parent Manual Consent
Please click and review the "Parent Manual" below.
Parent/Guardian #1 Signature
*
Parent/Guardian #1 Name
*
First Name
Last Name
Parent/Guardian #2 Signature
Parent/Guardian #2 Name
First Name
Last Name
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Child's Medical Information
Doctor's Name
*
Doctor's Phone Number
*
Please enter a valid phone number.
Doctor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Special Health Concerns: If your child has any known health conditions such as asthma, epilepsy, hemophilia, or adverse reactions to stings/bites/drugs etc. Please indicate below.
Allergies: If your child has any known allergies or food intolerance's, please specify and provide information of any procedures undertaken in case an emergency arises. Please indicate below.
Has your child had any of the following? (please check applicable)
Asthma
Chicken Pox
German Measles
Seizures or fainting
Hepatitis
Red Measles
Frequent Colds
Mumps
Whooping Cough
Rheumatic Fever
Diabetes
Scarlet Fever
Has your child had any recent medical operations? If so, please provide details below.
Special Needs: Does your child have any special needs? (Ie. diet, physical, emotional or learning etc.) If so, please provide details below:
Child Immunization Record:
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Please upload your child's Immunization record, or if your child is exempt, please upload a letter from your child's doctor.
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Sleep Arrangements
Please note that children under 12 months of age will be put to sleep on their backs as per requirements from Public Health Agency of Canada, and the Canadian Pediatric Society, unless otherwise specified in writing by a doctor. Should an infant roll over from their back to their side or stomach, it is suggested by the Canadian Pediatric Society that the infant NOT be re positioned.
I will be providing a note from my doctor with directions for my child to sleep on their stomach or side.
My Child will sleep on their: (please indicate below)
Back
Stomach
Side
I will be providing:
Blanket
Pacifier
Soft Cuddle Toy
Other
Child's Age at start date:
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Emergency Contacts
Please list below, two people other than yourselves, to whom your child can be released to, or that we may contact in case of an emergency.
Emergency Contact #1
*
First Name
Last Name
Home Number
Please enter a valid phone number.
Cell Number
*
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Relationship to Child
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact #2
*
First Name
Last Name
Home Number
Please enter a valid phone number.
Cell Number
*
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Relationship to Child
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Permission for Medical Treatment
In the event of an accident or illness involving my child, while my child is in the program, I hereby authorize the administration of any medical procedure deemed necessary, by the above named doctor, any hospital emergency department, or by any other qualified physician. In no case will Bizzy Buddies Inc., or any of its staff members, beheld financially liable for the cost incurred, as a result of any emergency procedures undertaken. I also give my child permission to participate in all activities and neighbourhood walks that are supervised by the staff of Bizzy Buddies Learning & Childcare Centre Inc.
*
I/we give permission for Medical Treatment
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Registration Fee
There is a one time non refundable registration fee of $250.00 payable at the time of registration.
*
1 Child = $250
Last Month Security Deposit
IMPORTANT: The security deposit will ONLY be applied to the family’s final tuition payment; PROVIDING receipt of a one month written notice of your child’s withdrawal from our program; and that your child(ren) have been attending Bizzy Buddies Childcare for a minimum of one month. Failure to provide a one month written notice and less than one month of childcare will result in a non-refundable deposit. NOTE: If you have registered your child and withdraw from the program prior to starting, your deposit will not be refunded, regardless of any written notice.
Toddler Security Deposit: (select the number of days/week your child will attend)
*
2 days/week = $350
3 days/week = $450
4 days/week = $550
5 days/week = $650
not applicable
Preschool Deposit: (select the number of days/week your child will attend)
*
2 days/week = $300
3 days/week = $400
4 days/week = $500
5 days/week = $600
not applicable
Payment Method
e-Transfers can be made to bb2payments@bizzybuddies.ca
Please select a payments method. (cheques will not be accepted)
*
Please Select
e-Transfer to bb2payments@bizzybuddies.ca
cash
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Child Questionnaire
Please describe your child’s previous care experience.(select all that apply)
Daycare
Home Care
Babysitter/Nanny
Other
How does your child interact with family members? (select all that apply)
Shy
Outgoing
Withdraw
Talks to them
Other
How does your child interact with visitors or other children?
What does your child like to do/play with on their own at home? (toys, books, computer, t.v., movies, games, etc.) How long/how often? How do they play with the materials?
What age did your child:
Sit on their own?
Begin to walk?
Start talking?
How does your child communicate? (select all that apply)
Verbally
Pointing
Gestures
Other
Does your child respond to his/her name?
Yes
No
When your child is upset/angry what do they do? (select all that apply)
Cry/Scream
Throw Object
Bite
Hit
Temper Tantrum
Other
Has your family been involved with any community agencies, supports or doctors? (please specify below or check not applicable)
not applicable
Halton Peel Preschool Speech and Language Program
Developmental Paediatrician
Erinoak
Brampton Caledon Community Living
Community Living Mississauga
PEP-Start Clinic
Peel Behavioural Services
Peel Children’s Centre
Children's Aid
Peel Infant Development
Credit Valley Hospital/Hospital for Sick Children/William Osler Health Centre
Other
Questionnaire completed by
First Name
Last Name
Date
-
Month
-
Day
Year
Date
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