Ktantanim Daycare - Registration Form

Child Care Centre Application for Enrolment

REGISTRATION FEE - A Non-Refundable $200 registration fee must be attached to the application in order to secure your spot.
Age Group Placement at Time of Enrolment:*

InfantToddlerPreschool
Hours of Care
Child Information
Full Legal Name:*
Preferred Name: *
Date of birth:*

MonthDayYear
Date
Age:
Home Address:*
Languages Spoken at Home
Other children in the family enrolled in the centre list names if applicable
Parent Information
Full Legal Name:*
Preferred Name:
Relationship to Child:*
Email addresses:*
example@example.com
Primary Phone Number:*
Alternate Phone Number:
Type a question

Same as child
Home Address
Full Legal Name
Preferred Name
Relationship to Child
Primary Phone Number:
Email addresses
example@example.com
Alternate Phone Number:
Type a question

Same as child
Home Address
Custody Arrangements (if applicable)
Are there custody arrangements pertaining to legal right of access to your child?*

YesNo
If YES, please provide a copy of the appropriate legal documentation (e.g., court order).
Names of custodial parents
Names of individuals prohibited from accessing/picking up your child
Emergency Contacts

In the event of an emergency, if a parent cannot be reached, the following individual(s) may be contacted. Please list in order of preference.
Emergency Contact #1
Type a question

Authorized to pick-up child
Full Legal Name
Preferred Name
Relationship to Child
Primary Phone Number
Alternate Phone Number
Home Address
Emergency Contact #2
Type a question

Authorized to pick-up child
Full Legal Name
Preferred Name
Relationship to Child
Primary Phone Number
Alternate Phone Number
Home Address
Emergency Contact #3
Type a question

Authorized to pick-up child
Full Legal Name
Preferred Name
Relationship to Child
Primary Phone Number
Alternate Phone Number
Home Address
Pick-Up Authorization

The following additional individuals are authorized to pick up my child (Photo ID will be required to confirm identify before the child will be released):
Full Legal Name - 1
Relationship to Child - 1
Primary Phone Number - 1
Please enter a valid phone number.
Full Legal Name - 2
Relationship to Child - 2
Primary Phone Number - 2
Please enter a valid phone number.
Full Legal Name - 3
Relationship to Child - 3
Primary Phone Number - 3
Please enter a valid phone number.
Additional Emergency Information
Please provide any special medical or additional information about your child that could be helpful in an emergency (e.g., known medical conditions, skin conditions, vision/hearing difficulties):
Health Information

If your child has had any history of communicable diseases (e.g., chicken pox, measles), please list them below (see Appendix C for common communicable diseases from Health Canada):
Does your child have any medical need(s) that requires additional support (e.g., Diabetes)?*

YesNo
If yes, an individualized plan for children with medical needs must be developed between the parent and the child care centre prior to the child’s first day of care.
Immunization Records
Please provide a copy of your child’s immunization record (e.g., yellow card) to the centre prior to your child’s first day of care. If you do not have an immunization record, please complete the chart below.

If you have chosen not to immunize your child, a Statement of Medical Exemption form or a Statement of Conscious or Religious Belief form must be completed and provided to the centre.

These forms are available on the Ministry of Education’s website.

Vaccine (Age Usually Given)

	Date	Date	Date	Date
DTaP-IPV-Hib (2 mos, 4 mos, 6 mos, 18 mos) Diphtheria, Tetanus, Pertussis, Polio, Haemophilus influenzae type b
Pneu-C-13 (2 mos, 4 mos) Pneumococcal Conjugate 13
Rot-1 (2 mos, 4 mos) Rotavirus
Men-C-C (12 mos) Meningococcal Conjugate C
MMR (12 mos) Measles, Mumps, Rubella
Var (15 mos) Varicella
MMRV (4-6 years) Measles, Mumps, Rubella, Varicella
Tdap-IPV (4-6 years) Tetanus, diphtheria, pertussis, Polio
Inf (every year in the fall) Influenza

Allergy Information
Does your child have a life-threatening allergy (e.g., anaphylactic to peanuts or bee stings)?*

YesNo
If yes, an individualized plan for an anaphylactic allergy that includes emergency procedures must be developed between the parent and the child care centre prior to the child’s start date.
Does your child have any allergies that are not life-threatening (food or other substance [e.g., latex])?*

YesNo
If yes, please provide relevant details, including what your child is allergic to, symptoms of a reaction and treatment required:
Dietary and Feeding Arrangements
Does your child have any special feeding arrangements (e.g., no sippy cups, mashed/pureed food)?*

YesNo
If yes please provide relevant details:
Does your child have any special dietary requirements or restrictions (e.g., vegetarian)?*

YesNo
If yes please provide relevant details:
Sleep Arrangements

*For children under 12 months, please complete, Appendix A: Supplementary Information for Children Under 12 Months.
How many naps does your child typically have each day
At what times does your child typically nap
How long does your child usually nap
Does your child have any special sleep requirements (e.g., specific comfort item, soother)?*

YesNo
If yes please provide relevant details:
Physical Requirements
Does your child use diapers?*

YesNo
If no, my child:

Uses the washroom independentlyRequires some assistanceRequires full support
Please provide relevant details:
Does your child require any additional support or accommodation with respect to physical activity?*

YesNo
If yes please provide relevant details:
Additional Information
Please indicate any additional information that is relevant to the care of your child (e.g., prone to colds, frequent shoulder dislocation, etc.):
Signature
Parent Name*
Parent Signature*

Clear
Date ddmmyyyy*

MonthDayYear
Date
Note: 'Parent' is defined as a person having lawful custody of a child or person who has demonstrated a settled intention to treat a child as a child of his or her family, and includes legal guardians.

Appendix B: Authorization for Non-Prescription Skin Products
Childs Full Legal Name
Date of Birth ddmmyyyy

MonthDayYear
Date
The following non-prescription items may be applied to my child in accordance with the manufacturer’s instructions on the original container (please check off):

SunscreenDiaper Creams/OintmentLip balmHand sanitizersInsect repellentLotions
Date ddmmyyyy

MonthDayYear
Date
Signature of Parent

Clear
Checklist for first day:
Should be Empty:

Child Information

Parent Information

Emergency Contacts

Emergency Contact #1

Emergency Contact #2

Emergency Contact #3

Pick-Up Authorization

Additional Emergency Information

Health Information

Immunization Records

Allergy Information

Dietary and Feeding Arrangements

Sleep Arrangements

Physical Requirements

Additional Information

Signature

Appendix A: Supplementary Information for Children Under 12 Months

Feeding Arrangements

Sleep Arrangements

Appendix B: Authorization for Non-Prescription Skin Products

Checklist for first day: