Enroll Your Child – kinderstars.ca

Blank Form (#4)

CHILD ENROLLMENT FORM

CHILD INFORMATION

Program

Date of Enrollment

Child's First Name

Child's Last Name

Child’s Date of Birth

School Attended (If applicable)

Hours of Care Required

Reason For Care

Child Resides With

Custody Agreement

Yes

Provide details of the agreement

Others in The Household and Relationship

PARENT/GUARDIAN INFORMATION

Parent/Guardian 1

Name

Address

Postal Code

Home Phone Number

Cell Phone Number

Employer Name

Occupation

Employer Address

Work Phone Number

Parent/Guardian 2

Name

Address

Postal Code

Home Phone Number

Cell Phone Number

Employer Name

Occupation

Employer Address

Work Phone Number

Please provide the full name, relationship, and phone number for two emergency contacts we can reach if needed.

Emergency Contact Detail 1

Name

Relationship

Address

Postal Code

Home Phone Number

Cell Phone Number

Employer

Work Phone Number

Emergency Contact Detail 2

Name

Relationship

Address

Postal Code

Home Phone Number

Cell Phone Number

Employer

Work Phone Number

HEALTH INFORMATION

Please answer the following questions regarding your child’s health and medical history.

1. Does your child have any physical disabilities?

If yes, please describe

2. Does your child have any chronic health problems such as Asthma, Allergies, Diabetes, Convulsions, etc.?

If yes, please describe

What is the reaction?

Procedure to follow if a reaction occurs?

3. Does your child take medication regularly? If yes, please list:

Name of medication

Dosage

Time

Name of medication

Dosage

Time

4. Does your child have any special dietary restrictions?

If yes, please list

5. How does your child react to minor injuries (bumps, scrapes)? What comforts him/her?

MEDICAL INFORMATION

Edmonton Health Care Number

Immunization Records Current And Up-To-Date

Yes

Note: A copy of your child's Edmonton Health Care Card and Immunization Records are required.

In the event of a medical emergency and I/We cannot be reached, I/We

hereby authorize KinderStars Child Care to obtain medical treatment for my child,

from my doctor or any other physician selected by the center.

Kinder Stars

Kinder Stars

CHILD ENROLLMENT FORM

PARENT/GUARDIAN INFORMATION

Please provide the full name, relationship, and phone number for two emergency contacts we can reach if needed.

HEALTH INFORMATION

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