Little Elmers Registration Form April 17

Little Elmers Childcare and Out of School Care

Registration Form Registration fee: $25 for one child OR $40 per family

E-transfer sent to littleelmerschildcaresociety@gmail.com

Applications will not be processed until payment is received
Child's Name
Date of Birth

MonthDayYear
Date
Childcare Program Required:

Infant (12MTH-19MTH)Toddler (19MTH-3YRS)Preschool (3YRS-6YRS)OSC (6YRS-12YRS)
Attendance: (Fulltime/Part time/Drop In)
Drop Off Time
Pick up Time
Child's Name
Date of Birth

MonthDayYear
Date
Childcare Program Required:

Infant (12MTH-19MTH)Toddler (19MTH-3YRS)Preschool (3YRS-6YRS)OSC (6YRS-12YRS)
Attendance: (Fulltime/Part time/Drop in)
Drop Off Time
Pick up Time
Child's Name
Date of Birth

MonthDayYear
Date
Childcare Program Required:

Infant (12MTH-19MTH)Toddler (19MTH-3YRS)Preschool (3YRS-6YRS)OSC (6YRS-12YRS)
Attendance: (Fulltime/Part time/Drop in)
Drop Off Time
Pick up Time
Child's Name
Date of Birth

MonthDayYear
Date
Childcare Program Required:

Infant (12MTH-19MTH)Toddler (19MTH-3YRS)Preschool (3YRS-6YRS)OSC (6YRS-12YRS)
Attendance: (Fulltime/Part time/Drop in)
Drop Off Time
Pick up Time
Mother's Name
E mail Address
example@example.com
Date of birth

MonthDayYear
Date
Place of Work
Hours of Work
Home Address
Phone (h)
(w)
(cell)
Father's Name
E mail Address
example@example.com
Date of birth

MonthDayYear
Date
Place of work
Hours of work
Home Address
Phone (h)
(w)
(cell)
Family Physician
Phone
Does your child/children have: ADHD /ODD /Autism /Down Syndrome/ Other: Yes or No? Please specify:
Other Medical Conditions
Known Allergies
Has your child been immunized? If yes, please specify immunizations received:
Tell us about your Child/Children:
1. How would describe your child/children's personality?
2. Does your child/children have any allergies or health problems? Does he/she take medications regularly?
3. What is your child/children's medical history?
4. Does your child/children have any diet restrictions?
5. What is your child/children's first language?
6. Little Elmers Childcare and Out of School Care welcomes families with diverse cultural backgrounds and wish to be supportive in any way possible. Please share with us practices that you would like our team of educators to support throughout your child/children's day. Please feel free to have ongoing discussions with the childcare educators.
7. What methods of guidance do you use with your child/children?
8. Who has previously cared for your child/children?
9. Please indicate if there are any special routines i.e. meals, sleeping habits, etc. in your child/children's daily life that you wish to continue?
10. What are some of your child/children's preferences, fears, or habits?
11. Please share with us any other information that you feel will help us to get to know your child/children better.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty: