Butterfly Childcare Enrollment Form

Butterfly Childcare

Enrollment Form
Child's Name*

First NameLast Name
Proposed Start Date

MonthDayYear
Note:

Please complete all the sections with the required information. Contact us if you have any questions while completing this form. You will be required to complete other supplementary forms and consent forms as a part of enrollment.

Personal Information
Child's Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Parent's/Guardian's Name-1 *

First NameLast Name
Contact Number*
Email*
Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Place of Work
Work Phone
Parent's/Guardian's Name -2

First NameLast Name
Contact Number
Email
Address

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Place of Work
Work Phone

Emergency Contact

Other than parents/guardian
Emergency Contact's Name (1)*

First NameLast Name
Contact Number*
Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Relationship to Child
Authorized to Pick up your child?*

YesNo
Emergency Contact's Name (2)

First NameLast Name
Contact Number
Address

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Relationship to Child
Authorized to Pick up your child?

YesNo
Authorized Person

Please list the names to whom child can be released if different than the emergency contact
Authorized Person-1
Authorized Person-2

Enrollment Information
Enrollment Schedule*
Subsidy Eligibility*
Any previous childcare experience?

YesNo
Name of previous childcare program
Things that comfort your child*
Favorite Toys/Games/Activities*
Cultural Celebrations at Home*
Child Guidance Strategies at Home*

Portable Emergency: Butterfly Childcare
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Health and Medical Information
Alberta Health Number*
Any Allergies or food restriction?*

YesNo
If 'YES', please explain...
Any ongoing medication?*

YesNo
If 'YES', please explain...
Any medical condition that our educators need to be aware of?*
Immunization Up to date?*

YesNo
If 'No' please explain
Parent/Guardian's Information
Parent/Guardian-1*

First NameLast Name
Contact Number (Personal)*
Contact Number (Work)
Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Parent/Guardian-2

First NameLast Name
Contact Number (Personal)
Contact Number (Work)
Address

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Emergency Contact

(Other than parents/guardians)
Emergency Contact-1*

First NameLast Name
Contact Number (Personal)*
Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Emergency Contact-2

First NameLast Name
Contact Number (Personal)
Address

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Parent/Legal Guardian Consent and Agreement for Emergencies*

I understand that Butterfly Childcare’s policy is to notify parents if a child is involved in any kind of serious illness or injuries while getting care at the center. The program will follow the instructions provided by parents.I hereby provide consent to Butterfly Childcare to contact my family physician or emergency medical service for my child if ever requires emergency medical attention.I hereby provide consent to release my child’s health record to emergency medical personnel while my child is getting medical attention.
Parent/Guardian's Name*
Signature*

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Butterfly Childcare

Note:

Personal Information

Emergency Contact

Authorized Person

Enrollment Information

Health Information

Consent for Emergency Medical Treatment

Enrollment and Policy Agreement

Portable Emergency: Butterfly Childcare

Health and Medical Information

Parent/Guardian's Information

Emergency Contact