Childcare Application Form Childcare Application Form Step 1 of 4 - Child Information 25% Date of admission* Month Day Year Child's Name* First Last Date of birth* MM slash DD slash YYYY Child's Name First Last Date of birth: MM slash DD slash YYYY Child's Name First Last Date of birth MM slash DD slash YYYY Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone Number*Email* Days of care needed* Hours of care needed* Mother's Name: First Last Mother's Cell:Mother's Work Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Father's Name First Last Father's CellFather's Work Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Guardian's Name First Last Guardian's Cell PhoneGuardian's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Authorized persons who are allowed to pick up your child:*List the names of up to three people who can pick up your child. In case of emergency medical treatment, the provider will administer First Aid, call 911, call the parents/guardian, and then contact the agency. Caregiver will use the information below if parents cannot be reached.Emergency Contact Name:* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Relation to child* What school does/will your child attend?* Doctor's Name:* First Last Phone*Doctor's Address* Address City Previous communicable diseases Previous illness or injury Special medical conditions or known allergiesEx: Diabetes, seizures, etc. Medication administered regularlySpecify name, dosage, and reason for medication. Special Diet Please comment on any other important information that is relevant for the provider to know in order to provide care for you childEx: Sleep routine, development, fears, etc. Permissions*I authorize the administration of sunscreen, diaper cream, Vaseline, and bug repellant as needed. I understand that it is my responsibility to provide the products to the provider in the original container with my child's name on it. Yes No Photo/Video Permissions*I grant permission to use photographs and/or videos taken of my child(ren) during his/her time in care to be used in text or email communication between parent, provider and agency, for promotion of our home childcare agency (newsletters and website) and for staff/provider training. Yes No Consent* I have read and agreed with the Parent Handbook policies and procedures.View our Parent Handbook.Parent's SignatureDate* MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
