CHILD ENROLLMENT FORM

I provide permission to Evolve Play | Train to prop my child's cot slightly if he/she is showing signs of congestions (i.e. stuffy/runny nose). Please do so at your discretion as well as we will inform you if it is felt elevation that is required.*

YesNo
I provide permission to the staff of Evolve Play | Train to apply non-prescribed creams, lotion lip balms that I provide for use by my child during operational hours of the program.*

YesNo
MEDIA RELEASE FORM
I hereby authorize the information contained in this registration form is truthful and correct as well as authorize the above individuals to be contacted if necessary for pick-up of my child, at which time they may be given information surrounding the daily activities and/or symptoms of ill health.
I provide permission to Evolve Play | Train, their successors, and their assignees the right to record the image and/or voice and use the artwork and/ or written work of my child, on videotape, on film, on photographs, in digital media and in any other form of electronic or print medium and to edit such recording at their discretion. I understand that my child's full name, address and biographical information will not be made public. I further grant Evolve Play | Train, their successors, and their assignees the right to use, and to allow others to use, my child's image and/or voice on the internet, in brochures, and in any other medium and hereby consent to such use. I hereby release Evolve Play | Train, their successors, and their assignees and any using my child's image and/or voice, artwork, and/or written work pursuant to this media release form any and all claims, damages, liabilities, costs and expenses which or my child now have or may hereafter have by reason of any use thereof. I understand that the provisions of this release are legally binding.*

Yes to photos/videos of my child aloneNo to photos/videos of my child aloneYes to group photos/videosNo to group photos/videos
Parent/Guardian Signature*

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Date Signed*

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Date

CHILD IMMUNIZATION STATUS DECLARATION

Community Care Facilities that are licensed to provide care to children are required to have a copy of the Immunization Status on file for each child in care if an outbreak of a communicable disease should occur. This information will assist in identifying those that may require exclusion because they are not immunized.

This form has been provided to: Assist in identifying those children who are not fully immunized and Assist licensees in meeting Section 21(1a) of the Child Care Licensing Regulation.
Name*

Child's Legal First NameChild's Legal Last Name
Child Immunization Status*

Complete and up to dateNot immunized/ NoneSomeI do not know
Child Immunization Records*

Records of Immunization attachedRecords unavailable
Immunization Record: please attach

Cancelof
Last Vaccination: YEAR*
City*
Province*
Country*
I hereby authorize the information contained in this registration form is truthful and correct.
Parent/Guardian Signature*

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Date*

MonthDayYear
Date

EMERGENCY PREPAREDNESS FORM
Child's Name*

First NameLast Name
Care Card Number*
Emergency Supplies

Evolve PLAY I TRAIN Emergency Preparedness Program requires that every child is provided at school, a comfort kit, designed to provide some short-term supplies and, more importantly, reassurance and comfort for your child in the event of an emergency or of an earthquake.

Evolve PLAY I TRAIN comfort kits contain supplies recommended by your Health Authority including such items as drinks and snacks. You will be charged a fee for the cost of the kit.

Out of Area Contact

Evolve PLAY I TRAIN is involved in an ongoing Emergency Preparedness Program. To ensure the safety of the children and staff, precautions - such as fire and earthquake drills are practiced regularly. An important part of this program involves issuing and maintaining personal photo ID tags. They would provide vital medical information in addition to assisting with a safe and speedy communication and reunion with family. This tag is for each individual child and includes information such as authorized persons to release the child to, name of the child, and other important details.

This form should be kept current, and any changes should be applied immediately, and the school office notified.

Considerations:

1. Alternative Person - In the event of a major emergency, your child would be released only to you (as a Parent or Guardian) or to one of the two individuals listed as Alternates in the Enrollment Form.

2. If possible, siblings should have the same Alternate Persons named to keep the family group together.

3. Out-of-Area Contact - In an emergency such as an earthquake, it is likely there would be considerable disruption to the telephone service. Families should plan to have an Out-of-Area Contact who could act as a central point for relaying of messages. It is recommended that your Contact Person be a minimum of 160km from your school's location.

4. Both the Alternate Persons and the Out-of-Area Contact need to know that they have been named and be aware of their role in the event of an emergency.
Out of Area Contact Person #1*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Out of Area Contact Person #2*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
I hereby authorize the information contained in this form is truthful and correct. *

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Date

INDIVIDUALIZED PLAN FOR A CHILD WITH MEDICAL NEEDS
Child's Name

First NameLast Name
Child's Photo

Cancelof
Date Individualized Plan Completed

MonthDayYear
Date
Medical Conditions:

DiabetesSeizureAsthmaOther
Prevention and Supports
Steps to reduce the risk of causing or worsening medical condition:
List of Medical Devices and How to use them
Location of Medical Devices
Supports Available to the Child
Symptoms and Emergency Procedures
Signs and Symptoms of Allergic Reaction or other Medical Emergency
Procedure to follow if child has an allergic reaction or other medical emergency
Procedure to Follow during an evacuation or during field trips
Additional Information Related to Medical condition (if applicable)
This plan has been created in consultation with the child's parents/guardians.

YES

Getting to Know Me !!!
While at Evolve PLAY I TRAIN we want your child to learn and discover, we recognize that this happens when a child feels safe, welcome, and happy. We want to surround your child with activities which they will enjoy and understand who they are as an individual. Please fill in the following form to help us to get to know more about your child and your family and help make a smooth transition.
Child's Name*

First NameLast Name
What would you like Evolve PLAY | TRAIN to be able to provide your child?*
Are there any circumstances in the family which may be a factor in your child's present behaviour? (i.e: recent move, new baby, sickness)*

NoYes, please describe below
Describe above factors
Does your child have any siblings? If yes, please list name and ages below*
Does your child have any pets? If yes, please list names and what type of animal*
Is there any holidays that your family does not celebrate? If yes, please list below*
Is your child a good eater?*

Good eaterAverage eaterPoor eater
Please list Favorite Foods*
Please list Foods that he/she Dislikes*
Soothing your child: When your child is upset or unhappy, what seems to comfort him/her? (Note any words or phrases from family's primary language)*
Child's Favorites:
Favorite Song:*
Favorite Book:*
Favorite Friend:*
Favorite Toy:*
Favorite Indoor Activity:*
Favorite Outdoor Activity:*
Child's Sleeping Habit:
Number of Naps per day:*
Approximate length of naps:*
Is there a particular way your child likes to be put to sleep? (i.e. back rubbed, being rocked, etc.*
Does your child require any of the following to allow him/her to feel more comfortable:*

BlanketStuffyOther
Please add additional comments which you feel would help us know your child better:*
I hereby authorize the information contained in this form is truthful and correct.*

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Date

PARENT HANDBOOK ACKNOWLEDGMENT FORM
After reading the Parent Handbook, please complete and sign.
Child's Name*

First NameLast Name
We have read and understand the contents of the Parent Handbook. We agree to follow, and the policies outlined in Parent Handbook. We understand that the school reserves the right to amend policies and procedures when necessary, and that we will abide by changes. Any changes made to the Handbook will be distributed by the School.

The Parent Handbook is not an enrollment contract.

Please Note: It is required that both/all parents sign this form. Thank you, very much!
Parent 1 Signature *

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Date*

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Date
Parent 2 Signature *

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Date
Should be Empty:

	YES	No
Chicken Pox
Seizures
Mumps
Asthma
Whooping Cough
Pneumonia
Measles
Hepatitis
German Measles
Scarlet Fever
Rheumatic Fever
Pink Eye
Skin Condition
Health Problem
Vision Difficulties
Parasites

CHILD HEALTH INFORMATION

EMERGENCY PREPAREDNESS FORM

ANAPHYLAXIS EMERGENCY PLAN

INDIVIDUALIZED PLAN FOR A CHILD WITH MEDICAL NEEDS

Getting to Know Me !!!

PARENT HANDBOOK ACKNOWLEDGMENT FORM