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Mayerthorpe Family and Community Support Services

Childs Name

Alberta Health Care #

Date of Birth

Date

Address

Parent #1 Name

Email Address #1

example@example.com

Date of birth

Date

Place of Work

Hours of Work

Home Address

Phone (h)

work

cell

Parent#2 Name

Email Address #2

example@example.com

Date of birth

Date

Place of Work

Hours of Work

Home Address

Phone (h)

work

cell

Custody Order on File? Y or No Conditions

Emergency Contacts (local and other than parents)

Emergency Contact #1

Relationship to Child

Home Phone

Work

Cell

Emergency Contact #2

Relationship to Child

Home

Work

Cell

Pick-Up Authorization: (name & phone number)

Person #1

Person #2

Family Physician

Phone

Does your child have: ADHD/ODD/Autism/Down Syndrome/Other? YES or NO

Other Medical Conditions

Has your child been immunized? Yes or No

Known Allergies

TELL US ABOUT YOUR CHILD

Your childs name

Nickname

Brothers Names

Sisters Names

1. How would you describe your child's personality?

2. What is your child's first language?

3. Mayerthorpe Playgroup 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's day. Please feel free to have ongoing discussions with childcare educators.

4. What methods of guidance do you use with your child?

5. Who has previously cared for your child?

6. Please indicate if there are any special routines that your child currently uses.

7. What are some of your child's preferences fears or habits?

8. Please share with us any other information that your feel will help us to get to know your child better.

* Parents will be asked to review emergency information every six months and initial to confirm accuracy*

Guardian Signature

Date

Please select which class you would like to register your 3 or 4 year old child.

** This does not guarantee your child will be in the class you select as Educators need to ensure appropriate class sizes to meet the developmental needs of the children**

Affordable Funding Paid to the Program - $100 per month

Mayerthorpe Playgroup start date is September 8, 2025 for 3 and 5 day classes. September 10, 2025 for the 1 day class. Classes end June 15th week 2026.

Age Category

Class Selection

Hours

PARENTAL AGREEMENT

1. I understand and hereby agree that the fees are due on the first of each month and that no refunds are given for absent days.

2. I understand and hereby agree to make payments via debit at the Town Office.

3. If payment for childcare fees is not received within the first 5 days of the month, a $50 fee will be charged for late payment. Mayerthorpe Playgroup has the right to refuse services for your child if payments are in arrears by more than 5 business days.

4. I understand that the hours of operation in which my child is enrolled and will ensure that I drop off and pick up my child on time. I will notify the Educators if I am running late.

5. I agree to give permission for my child to take part in any activities and outings that are planned and supervised by the Educators. I understand that when special trips are planned, I will be notified and asked to give written permission prior to my child leaving the center premises.

6. The childcare educators will support children to keep their belongings safe, but I understand that the center is not responsible for any lost personal belongings.

7. I understand that as a courtesy I will inform the staff by 8:00am if my child will not be attending that day. This may be through the Remind app or a phone call to the program.

8. I agree that all personal belongings that are brought into the childcare center will be labeled with my child's name on them.

9. I agree to report any sickness/communicable diseases/medication that my child has or is taken as soon as my child has been giving a diagnosis.

10. Over the counter medication and prescription medications are required to have a Physicians label and a medication form from Lit.

11. It is crucial that you sign your child in and out daily.

Guardian Signature

Date

Mayerthorpe Playgroup Registration Form