Pre-Kindergarten Registration Form

Registration

Chlid Care Location & Program(Required)

Grade(Required)

Start Date(Required)

Child's Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth (yyyy/mm/dd)(Required)

MCP #(Required)

Expiry Date (yyy/mm/dd)(Required)

1. Parent/Guardian Name(Required)

Tel (h)(Required)

(w)(Required)

(c)(Required)

1. Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

1. Work Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

1. Email Address(Required)

2. Parent/Guardian Name

Tel (h)

(w)

(c)

2. Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

2. Work Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

2. Email Address

In care of Emergency (adult to contact if you cannot be reached). Name:(Required)

Relationship(Required)

Tel (h)(Required)

(w)(Required)

(c)(Required)

Physician and/or Clinic Name(Required)

Physician Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tel(Required)

Dentist and/or Clinic Name(Required)

Dentist Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tel(Required)

Health Questionnaire

Describe your child’s general health, (e.g., Recurrent colds, ear infections, stomach aches, etc.)(Required)

Does your child have any illnesses, conditions, or special needs which we should know about, (e.g., asthma, ADHD)?(Required)

Is your child taking any medication?(Required)

Yes

If yes, please list name of the medication(s) for each condition(Required)

Has your child ever been to a dentist?(Required)

Yes

Describe any dental problems(Required)

How would you describe your child’s emotional, physical, and social growth and development?(Required)

Does your child have any food allergies?(Required)

Yes

If yes, please describe(Required)

Does your child have any other allergies?(Required)

Yes

If yes, please describe(Required)

Is your child on any special diet?(Required)

Yes

If yes, please describe(Required)

Describe any concerns you have about your child’s diet and/or eating habits(Required)

Describe any fears your child has shown (e.g., animals, loud noises, strangers)(Required)

Describe how your child reacts to stressful situations (e.g., cries, withdraws, ‘acts out’, runs away)(Required)

How does your child usually react to new situations?(Required)

Describe specific techniques used to settle or calm (e.g., quiet time with an adult for preschoolers, or time to themselves)(Required)

Describe your child’s sleeping habits and routine(Required)

How far has your child progressed in toilet learning (if applicable)(Required)

We would appreciate your views on guiding your child’s behaviour and setting limits(Required)

Is there anything else that you would like to tell us about your child? (e.g., if your child requires 1-1 support; extra support for transitions, etc.)(Required)

Statement of Immunization

This is to confirm that (name of child or individual)(Required)

statement(Required)

is not immunized

does not have a current and up to date record of immunizations

is awaiting a copy of my/child's record of immuniztion

I, the parent/guardian, am aware that I/my child may be asked to leave the child care program listed below at the request of Public Health official in the event of a communicable disease outbreak and may be unable to return for the duration of the outbreak. List the child care location:(Required)

Alternate Pick-Up List

Site(Required)

Phone Number(Required)

Entrance Location(Required)

Alternate pick-up list (for persons other than the parents/guardians) who may be allowed to pick up your child/children. Consent it required. Photo ID will be required on pick-up to verify your identity. Child's name:(Required)

1. Name(Required)

Relationship to Child(Required)

Alternative Pick-up Phone Number(Required)

2. Name

Relationship to Child

Alternative Pick-up Phone Number

3. Name

Relationship to Child

Alternative Pick-up Phone Number

Payment Information

Pre-Authorized Payments (PAPs) is applied to personal bank accounts (a void cheque or pre-authorized payment form from your bank is required). Fees are charged on a bi-weekly basis (1st & 15th of every month) to your bank account. In some cases, your payment date may change, for example if your Payment Method has not successfully settled. Note: it may take a few days for the charge to post to your account. NSF Policy: The YMCA is not responsible for bank fees incurred due to non-sufficient funds (NSF). Balances owing must be paid in full to continue child care services. Fee Changes: Notification will be provided to the email and/or mailing address on file a minimum of 15 days prior to any scheduled change in fees.

Please attach (upload) a void cheque or pre-authorized debit form from your financial institution, to process the bi-monthly child care fees.(Required)

Max. file size: 256 MB.

Will there be split billing?

Yes

Do you currently have or will be applying for childcare subsidy?(Required)

Yes

Notice to Parent:

When this registration request has been submitted, you will receive a confirmation email stating we have received your request. The Provincial Registrar will then process your registration request and send another email to you that will include a payment plan showing future scheduled payments that will occur on the 1st and 15th of all months for which your child(ren) have been registered. No payment is due upon registration.

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