Village Childcare Registration Form

Child Registration Form
Child's Information
Photo of your Child
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Child's Care Card Number
Child's Sex
Child's Hair Color
Child's Eye Color
Distinctive Marks
Parent and Guardian Information
Parent or Guardian #1

First NameLast Name
Parent or Guardian #1 Primary Phone Number
Please enter a valid phone number.
Parent or Guardian #1 Secondary Phone Number
Please enter a valid phone number.
Parent or Guardian #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Parent of Guardian # 2

First NameLast Name
Parent of Guardian #2 Primary Phone Number
Please enter a valid phone number.
Parent of Guardian #2 Secondary Phone Number
Please enter a valid phone number.
Parent or Guardian #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Child Lives With
Child's Medical Information
Child's Doctor

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Allergies
Additional Health Issues
Emergency Contacts
Emergency Contact #1

First NameLast Name
Emergency Contact #1 Phone Number
Please enter a valid phone number.
Emergency Contact #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #2

First NameLast Name
Emergency Contact #2 Phone Number
Please enter a valid phone number.
Emergency Contact #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Person's allowed to Pick up Child from Care
Person's Not Permitted Contact with Child
Court Documentation (Required)
Agreement Conditions
Any pick up person unfamiliar to me will be required to show proof of identification. Under NO circumstances will the child be released to anyone other than those listed in the parent and pickup person sections above without WRITTEN permission from the parent.

When my child is ill, I understand and agree that Village Daycare will not accept my child for care as per the policy handbook. This includes: fever, diarrhea, vomiting, bad cough, communicable disease inability to participate in the day’s activities, or any condition which requires individualized attention beyond what we are capable of providing.

I certify that my child is, to my knowledge, in good health, and free of disabilities that would endanger him/her or other children.

By signing below, you agree that this is a legally binding form. Providing false information will result in termination of childcare services, and forfeiture of registration and other paid fees.
Signature Parent or Guardian #1

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Date

MonthDayYear
Date
Signature of Parent or Guardian #2

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Date

MonthDayYear
Date
Agreement
Monthly Fees: As described above.
Other Charges:
Overtime rate As described above
Late Payment Fee $5.00/day (after the 15th of the month)
NSF Checks $25.00/item
Late payment $5.00/day
Meal Provided Fee $10.00+ cost of meal
Snack Provided Fee $5.00
Diaper Provided Fee $2.00/diaper

By signing below, I confirm that I have read the Parent Policy Manual for Village Childcare and agree to abide by the policies and procedures found within. I recognize that changes and additions may be made to the daycare’s policies and procedures without my prior consent.
Signature or Parent or Guardian #1

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Date

MonthDayYear
Date
Signature of Parent or Guardian #2

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Date

MonthDayYear
Date
EMERGENCY MEDICAL TREATMENT PERMISSION FORM

I, First Name Last Name (parent/guardian), hereby grant my consent for
First Name Last Name (child’s name), to be given emergency treatment by a staff member at Village Daycare and/or for him/her to be given emergency medical or surgical treatment as prescribed by a treating physician. I also give permission for my child to be transported by car or ambulance to an emergency centre for treatment and agree to hold Village Childcare and its employees harmless.
Signature

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Date
PERMISSION FOR PICTURES AND VIDEOS

I, First Name Last Name (parent/guardian), hereby grant my consent for First Name Last Name (child’s name), to be photographed and/or videotaped while at Village Daycare.
I, grant my consent for Village Childcare to place photographs of my child on the centres’ website. I have viewed the web site and have found it to be of quality and is deemed appropriate.
I understand these pictures and videos will not be used for purposes other than www.thevillagecc.ca and/or distribution to the child’s parents/guardian and the other children’s parents/guardians at the facility via newsletters, posted on walls, etc. . .unless express permission is granted.
Signature

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Date
I First Name Last Name (parent/guardian), hereby give my consent for Village Childcare staff, to apply sunscreen to First Name Last Name (child’s name), to exposed skin areas before going outside on sunny days as directed by the sunscreen manufacturer.
I agree to provide the caregiver/daycare with the sunscreen with a sun protection factor (SPF) of 15 or more (without Paba), in its original container outlining full instructions, and clearly marked with my child’s name in permanent marker.
Signature

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Date
WATER PLAY PERMISSION

I, First Name Last Name (parent/guardian), hereby grant my consent for First Name Last Name (child’s name), to participate in water related activities including but not limited to water sensory play, backyard swimming pool and sprinkler activities, water bottles, and bathing a soiled child if necessary, while at Village Childcare.
I understand these activities will be vigilantly monitored at all times.
I will ensure that my child is sent with extra clothing daily. (Including underwear, socks, shirt pants,
etc. . .)
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Date
Should be Empty:

Child Registration Form

Child's Information

Parent and Guardian Information

Child's Medical Information

Emergency Contacts

Agreement Conditions

Agreement