Gateway Holistic
9218 Ellerslie RD SW, Ste 195,
Edmonton, AB, T6X0K6
admin@gatewayholisticcare.com
www.gatewayholisticcare.com
(780) 239 6674
Summer Program Registration Form
Child's Information
Please complete a form for each child being registered.
Are you already a client of Gateway Holistic? If not, please complete our Online Intake Form after submitting this registration.
*
Yes
No
Child's Full Name
*
First Name
Last Name
Child's Birthday
*
-
Month
-
Day
Year
Date
Allergies (If any)
Additional Information (If any)
Program:
*
Day Program
Week Program
Month Program
Full Spring Program
Full Summer Program
Date
*
-
Month
-
Day
Year
Parent Information
Parent's Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Relationship to child:
*
Primary language spoken at home:
*
What level of care do you require?
*
Level I
Level II
Level III
Impairment Level:
*
Alert
Alert (Occasional Confusion)
Mild Impairment (Some Confusion)
Moderate Impairment (Confused, memory trouble)
Severe Impairment (Affects All Aspects of Life)
Risk Factors - Please select all that apply.
*
Combative
Disruptive
Withdrawn
Self-harm Tendencies
Wanderer
Repetitive
Abusive (mentally/physically)
None
Please describe any dietary requirements:
*
Please list any sensitivities:
*
e.g., noise, crowds, etc
Do you require wheelchair accessibility?
*
Yes
No
Please provide a schedule and list of any daily medications that will need to be administered:
*
FSCD Caseworker
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Please Upload your FSCD Contract
*
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PHOTO DISCLAIMER: By proceeding, you hereby grant Gateway Holistic Care Group permission to take and use photographs of your child for marketing and promotional purposes. You acknowledge and agree that these images may be used by the company in various publications, press releases, promotional activities, or on the company's website. By providing your consent, you release and discharge Gateway Holistic Care Group from any and all claims arising out of the use of these photographs. Have you read and understand these terms?
*
Yes
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