online-application – Little Pearls

Registration Form
Name of Child:
Program Room :
Birth Date :
MM slash DD slash YYYY
Date of Application :
MM slash DD slash YYYY
First Day of Care :
Date of Enrollment :
MM slash DD slash YYYY
Child's Address :
Postal Code :
Telephone
Name of Mother/Guardian #1 :
Address:
Postal Code:
Home Phone:
Email Address:
Cell Number
Occupation:
Work Number:
Employer:
Work Hours:
Employer’s Address:
Name of Father/Guardian #2:
Address:
Postal Code:
Home Phone:
Email Address:
Cell Number
Occupation:
Work Number:
Employer:
Work Hours:
Employer’s Address:
REGULAR EMERGENCY CONTACTS (Note: Emergency contacts are people other than the guardian(s) who can be contacted and are able to pick-up your child, if an emergency situation occurs). Please obtain consent before naming someone as an emergency contact). This is a requirement from Alberta Child and Family Service Authority.
Name:
Name:
Address:
Address:
Postal Code:
Postal Code:
Home No:
Home No:
Work No:
Work No:
Relationship to child:
Relationship to child:
Authorized persons to whom the child may be released:
1. 2.
Name anyone who is not allowed access to the child:
Please indicate type of care needed:
- Full Time
- Part Time
Time and Days:
Reason for Care:
Family Information:
Marital Status:
- Single
- Married
- Separated
- Widowed
- Divorced
- Common-Law
If divorced or separated, please answer the following:
How long have you been separated?
Does your ex-spouse have contact with the child?
How often? When? _
Are there any concerns regarding your ex-spouse that we should be aware of?
Do you have a Court Order?
Other Children in the Family:
Name
Age
School
Child Care
Other Information
Name
Age
School
Child Care
Other Information
Name
Age
School
Child Care
Other Information
Family’s Child Guidance Method:
Kindly indicate your family traditions and/or cultural heritage:
Language/s spoken at home:
What activities does your child enjoy the most while playing by him/herself?
What kind of activities does your child enjoy doing with his/her siblings,other children or family?
Does your child have any strong interests or hobbies?
What sports is your child interested in?
Was there any previous experience in Child Care?
- YES
- NO
If yes, please describe:
Comments (Information that would affect the care of your child):
Are there any activities you would like to see included in the child care program?
HEALTH RECORD
Alberta Health Card No:
ALLERGIES (Please indicate no, only if your child has received allergy testing)
- YES
- NO
- None Known
Allergen/s:
How severe are your child’s allergies?
What signs/symptoms does he/she display when exposed to the allergen/s?
What action is taken at home when the child is exposed to an allergen?
Medication for Allergens:
Food Restriction:
Child’s reaction to illness, injury or stress:
Does your child have any particular, fears or dislikes?
Does your child have any exceptional physical needs or ongoing illness?
Has your child had any medical/emotional condition he/she is being tested and/or treated for?
- YES
- NO
If YES, please explain.
Is your child on any daily medication?
- YES
- NO
If YES, please indicate which medication(s)
What is the medication for?
When is the medication administered?
Is your child’s immunization up-to-date?
- YES
- NO
If no, please explain:
Child’s Physician Information: (If you don’t have a physician, indicate the clinic you regularly go to)
Name:
Phone:
Address:
MEDICAL HISTORY
Ears
- YES
- NO
If YES, please explain
Speech
- YES
- NO
If YES, please explain
Hearing
- YES
- NO
If YES, please explain
Vision
- YES
- NO
If YES, please explain
Eating
- YES
- NO
If YES, please explain
Sleeping
- YES
- NO
If YES, please explain
Bowel Movement
- YES
- NO
If YES, please explain
Wetting
- YES
- NO
If YES, please explain
Fever
- YES
- NO
If YES, please explain
Is your child developing as you think he/she should for this age?
- YES
- NO
If no, please explain
Please indicate if your child had any of the following:
Rubella
- YES
- NO
Date
MM slash DD slash YYYY
Measles
- YES
- NO
Date
MM slash DD slash YYYY
Chicken Pox
- YES
- NO
Date
MM slash DD slash YYYY
Whooping Cough
- YES
- NO
Date
MM slash DD slash YYYY
Mumps
- YES
- NO
Date
MM slash DD slash YYYY
Tuberculosis
- YES
- NO
Date
MM slash DD slash YYYY
Jaundice
- YES
- NO
Date
MM slash DD slash YYYY
Poisoning
- YES
- NO
Date
MM slash DD slash YYYY
Convulsions
- YES
- NO
Date
MM slash DD slash YYYY
Diabetes
- YES
- NO
Date
MM slash DD slash YYYY
Heart Condition
- YES
- NO
Date
MM slash DD slash YYYY
Epilepsy
- YES
- NO
Date
MM slash DD slash YYYY
Head Injury
- YES
- NO
Date
MM slash DD slash YYYY
Surgery
- YES
- NO
Date
MM slash DD slash YYYY
FAMILY ACKNOWLEDGMENT

Please read and initial accordingly. If you have any questions and/or clarification, please feel free to discuss this with the Director.
CHILD GUIDANCE POLICY
- I have read and understand the child guidance policy (as outlined in the Enrollment Handbook). The staff are trained upon hire to adhere to LPDC Child Guidance Policy. I also understand that corporal punishment (hitting, slapping, etc.) will never be used under any circumstances.
(Initial in the box provided)
DEPOSIT
- I understand that I am required to give Little Pearls Daycare a $100.00 space deposit in order to enroll my child in the program. This deposit is non-refundable.
(Initial in the box provided)
FIRST AID
- In the event of an emergency, I authorize LPDC staff to provide any first aid care deemed necessary for my child.
(Initial in the box provided)
EMERGENCY CARE
- In the event of an on-site incident requiring emergency care, I authorize LPDC to call 911. On off-site activity requiring emergency care and I authorize LPDC call 911. The physicians are authorized to provide any emergency care deemed necessary for my child. I understand LPDC will continue to try to locate myself or the emergency contacts named in this registration form. I will be responsible for all expenses incurred in providing care for my child.
(Initial in the box provided)
SUNSCREEN
- I authorize LPDC to use Coppertone Kids with SPF 60 on my child.
(Initial in the box provided)
INSECT REPELLENT
- I authorize LPDC to use Off Skinstastic Lotion on my child. (Off Skinstastic Lotion repels mosquitoes for 2 – 3 hours and have less than 10% deet. The product may have some nut and/or PABA (4-aminibenzoic acid)
(Initial in the box provided)
_____________ ONLINE PROGRAM
- I authorize LPDC to post daily reports about my child’s activities using the ______ Application to be accessed by our family and other authorized person/s through cellphones and other electronic devices.
(Initial in the box provided)
PICTURE CONSENT
- I authorize LPDC to photograph my child and our family for the LPDC website, bulletin board display, emergency record, memory scrapbooks for staff and children leaving LPDC. I authorize LPDC to use and present my child’s photo to authorized person/s in case of an emergency situation i.e. missing child on site and on off-site activity.
(Initial in the box provided)
SOCIAL MEDIA
- I authorize LPDC to share my child’s photo/s taken during LPDC Events and Celebration.
(Initial in the box provided)
COMMUNITY VISITS
- I consent to my child participating in the local neighborhood walks and field visits. The consent is valid for my child to visit the following places with the supervision of the staff. LPDC will post notice on the trip that the children will be going on. This consent is valid to sites within the Trumpeter Community: Community Park and Playground (across Little Pearls Day Care and Preschool_ Trumpeter Walking Trail (within Trumpeter’s perimeter) Big Lake Mart I will be required to sign a separate field trip form with any trips outside of the above listed
(Initial in the box provided)
ENROLLMENT HANDBOOK
- I have read the enrollment handbook that was provided to me. I read its contents and I agree to comply with the LPDC policies and procedures as indicated in the handbook.
(Initial in the box provided)
Parent/Guardian’s Signature Over Printed Name
Date
MM slash DD slash YYYY
Director’s Signature
Date
MM slash DD slash YYYY

Registration Form