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Child Care Registration Form 

CHILD’S INFORMATION

Child’s Full Name: ____________________________________  Birth Date: _____/_____/_____ 
Address: ____________________________________________ Home Phone: _______________
City: ___________________________ Prov./State: _________PC/Zip Code: ________________ 
Nickname: _______________________________

PARENT/GUARDIAN INFORMATION

Mother’s Full Name: ________________________________ Home Phone: _________________
Address: ________________________________________________________________________
City: _____________________________ Prov./State: _________PC/Zip Code: _______________
Occupation: _____________________________ Work Phone: ___________________ext.:______
Name of Employer:_______________________ Pager or Cellular Phone: ____________________
Business Address: __________________________________ City: __________________________
Work Hours: ___________________________ Driver’s License # :_________________________

Father’s Full Name: _________________________________ Home Phone: ________________
Address: ________________________________________________________________________
City: _____________________________ Prov./State: _________PC/Zip Code: _______________
Occupation: _____________________________ Work Phone: ___________________ext.:______
Name of Employer:_______________________ Pager or Cellular Phone: ____________________
Business Address: __________________________________ City: __________________________
Work Hours: ____________________________ Driver’s License #:_________________________

Parent/Guardian with legal custody: _________________________________________________
Parents are: __Married   __ Living Together  __Divorced   __Separated   __Widowed   __Single 

CHILD PICK-UP INFORMATION
Please list below the people who have *Permission* to pick up your child.  *Note:  Anyone picking up your child must have picture ID.

Name: __________________________ Phone: _________________ Relationship: __________
Name: __________________________ Phone: _________________ Relationship: __________ Name: __________________________ Phone: _________________ Relationship: __________

Please list those persons who *Do Not Have Permission* to pick up your child and explain the reason below or talk to your caregiver so she is aware of the situation.

Name: __________________________ Phone: _________________ Relationship: __________
Reason: _________________________________________________________________________

Name: __________________________ Phone: _________________ Relationship: __________ 
Reason: _________________________________________________________________________

EMERGENCY CONTACTS

Primary Emergency Contact (other than parents or guardian) 
Name: ________________________________________________
Home Phone: _______________________________ Work Phone: __________________________
Relationship to Child: ______________________________________________________________
Address:_________________________________________________________________________

Secondary Emergency Contact (other than parents or guardian) Name: ________________________________________________
Home Phone: _______________________________ Work Phone: __________________________
Relationship to Child: ______________________________________________________________
Address:_________________________________________________________________________

Any special instructions on how to reach parents: ________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________

EMERGENCY INFORMATION
1. Child’s physician: ________________________________ Phone: ________________________
2. Preferred hospital: _______________________________ Phone: ________________________
3. Child’s dentist: __________________________________ Phone: ________________________
3. Insurance company: ______________________________ Policy #: ______________________
4. Regular medications: ____________________________________________________________
5. Blood type: ___________________________________________________________________
6. Medicine allergic to: ____________________________________________________________
7. Food allergies: ________________________________________________________________
8. Any other allergies: ____________________________________________________________
9. Immunization record - Date of last immunization:____________________________________
10. Any special health conditions: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11.  Child has had:						Child suffers from:
	[  ]  Measles						[  ]  Headaches
	[  ]  German Measles					[  ]  Earaches
	[  ]  Chicken Pox					[  ]  Sore Throat
	[  ]  Mumps						[  ]  Stomach Aches
	[  ]  Whopping Cough					[  ]  Flu / Colds
	[  ]  Other _____________				[  ]  Other _____________

IMMUNIZATION RECORD

DPT	1. ___/___/___   2. ___/___/___   3. ___/___/___   4. ___/___/___   5. ___/___/___

Polio	1. ___/___/___   2. ___/___/___   3. ___/___/___    4. ___/___/___   5. ___/___/___  

MMR        ___/___/___	Measles     ___/___/___     Mumps   ___/___/___

Rubella     ___/___/___    TB     ___/___/___    HIV     ___/___/___     HIB     ___/___/___ 

OTHER IMPORTANT INFORMATION/PROVISIONS

Child will need special provisions such as:

[  ]  	Travel to and from school.

[  ]  	Extra curricular activity.    [  ] Yes  [  ] No
If yes, please give details: (i.e.: what activity, when, if transportation is required, specific arrangements to attend with other family members/friends, etc.) 
	__________________________________________________________________________
	__________________________________________________________________________

[  ]  	Other provisions we should be aware of: _________________________________________
	__________________________________________________________________________
	__________________________________________________________________________

Do you have any outstanding concerns?________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________ 

EMERGENCY RELEASE

Consent to Emergency First Aid & Transportation: 

I, ____________________________ (parent/guardian), hereby grant my consent for 
______________________________ (child’s name), to be given emergency treatment by a staff member at ____________________________ (daycare). I also give permission for my child to be transported by car or ambulance to an emergency centre for treatment, and agree to hold ________________________________________________________________ and its employees harmless.

Parent’s Signature ______________________________________ Date: _____________________

Consent to Medical Care and Treatment: 

In the event that I cannot be contacted immediately during a medical emergency, 
I, ____________________________ (parent/guardian), hereby grant my consent for 
______________________________ (child’s name), to be given emergency medical or surgical 
treatment as prescribed by a treating physician, and hold ________________________________ (caregiver/daycare), and its employees harmless.

Parent’s Signature ______________________________________ Date: ____________________

Consent to Administer Medication: 

In the event that my child is ill, I, _________________________________ (parent/guardian), grant my consent for _______________________________ (caregiver/daycare), to administer medication to _________________________ (child’s name), as prescribed by a treating physician or by me, the parent, for over-the-counter medications as follows:

Name of medication: _____________________  Date to begin: ___________ End: ___________
Amount of dose: _________________________ Times to be given: ________________________
Additional instructions: ____________________________________________________________
Possible side effects: ______________________________________________________________

Parent’s Signature ____________________________________ Date: _______________________