ICA registration form

Child's Name

First NameLast Name

Gender

Name Child Responds To:

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Mother's Name

First NameLast Name

Place of Employment

Home Number

Please enter a valid phone number.Format: (000) 000-0000.

Work Number

Please enter a valid phone number.Format: (000) 000-0000.

Cell Number

Please enter a valid phone number.Format: (000) 000-0000.

Address (if different from child's):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Father's Name

First NameLast Name

Place of Employment

Home Number

Please enter a valid phone number.Format: (000) 000-0000.

Work Number

Please enter a valid phone number.Format: (000) 000-0000.

Cell Number

Please enter a valid phone number.Format: (000) 000-0000.

Address (if different from child's):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Person Authorized to Pick up Child (other than parents listed above)

First NameLast Name

Relationship

Home Number

Please enter a valid phone number.Format: (000) 000-0000.

Work Number

Please enter a valid phone number.Format: (000) 000-0000.

Cell Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact (other than parents listed above)

First NameLast Name

Relationship

Home Number

Please enter a valid phone number.Format: (000) 000-0000.

Work/Cell Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact (other than parents listed above)

First NameLast Name

Relationship

Home Number

Please enter a valid phone number.Format: (000) 000-0000.

Work/Cell Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact (other than parents listed above)

First NameLast Name

Relationship

Home Number

Please enter a valid phone number.Format: (000) 000-0000.

Work/Cell Number

Please enter a valid phone number.Format: (000) 000-0000.

Person NOT Authorized to Pick up Child (other than parents listed above)

First NameLast Name

Relationship

Home Number

Please enter a valid phone number.Format: (000) 000-0000.

Work/Cell Number

Please enter a valid phone number.Format: (000) 000-0000.

*Please note: If there is a Custody Agreement, please give details below. A copy of the custody agreement must be provided to the owner.

COPY OF CUSTODY AGREEMENT

Doctor's Name

Name of Doctor's Office

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Card Number

Dentist's Name

Name of Dentist's Office

Consent for Emergency CareI authorize the staff of Inspired Care Agents to call a medical practitioner or ambulance in the case of accident or illness of my child, if the parents cannot be reached immediately.

Regular medication (s) and reasons for (please list):

Allergies/Reactions and treatments, please list and describe, below:

Any concerns/issues regarding your child’s health (seizures, asthma, vision, hearing, etc)Please list and describe, below:

Any concerns regarding your child’s development (behavior, speech, language, mobility, etc)Please list and describe, below:

Please list any specific care instructions regarding the questions above:

Other health care professionals involved in the care of your child (OT, PT, Speech, etc.):

Has your child had previous Daycare experiences? If yes, how did he/she adapt?

What is/are your child’s favorite toys/activities?

How does your child behave around other children? (seeks other out, feels shy, etc.)

How does your child react when left with unfamiliar people and/or in unfamiliar situations?

What suggestions do you have that would help staff ease your child’s transition into the program?

Please list the name(s) of the significant people in your child’s life (siblings, grandparents, etc):

Primary language(s) spoken at home:

Other language(s) spoken at home:

Any other comments

Signature of Parent providing information

Documenting the Centre’s activities is a part of our program. From time to time your child’s picture may be taken. Pictures taken will be used as displays in the classroom only. I, ____________________________ understand that photos my be taken of my child as they take part in the daily activities at the daycare. I give the staff of Inspired Care Agents permission to take photos and display in the classroom.

Inspired Change Agents its own website and Facebook page. This page is a place to communicate, see updates on the daycare, view pictures of your child’s day, and for people to see firsthand what Inspired Change Agents is all about. To post any photos, Inspired Change Agents needs your written consent to do so. Please fill out the appropriate section below. I DO give Inspired Change Agents permission to post photos of my child(ren)o n their Website/Facebook page. I understand that these photos can be viewed by anyone who accesses the platforms OR I, DO NOT give Little Treasures Daycare permission to post photos of my child(ren) on their Facebook page.

Signature

Registration Form