Surrey, British Columbia BC V3T 5A5
(604) 588-6613; (604) 771-6825
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[vc_row][vc_column el_id=”registerform”]
"
*
" indicates required fields
Phone
This field is for validation purposes and should be left unchanged.
Contact Information
Child's Full Name:
*
Child's Nickname:
*
Birthdate:
Date of Enrolment:
Home Phone:
Address:
City
Provience
Postal code
Mother's Information
Mother's Full Name:
Mother's Home Phone:
Mother's Address:
City
Province
Postal code
Mother's Employer
Mother's Employer:
Mother's Occupation:
Hours at Work:
Days at Work:
Work Phone:
Cell Phone:
Employer's Address:
Untitled
Province
Postal code
Father's Information
Father's Full Name:
Father's Home Phone:
Father's Address:
City
Province
postal code
Father's Employer
Father's Employer:
Father's Occupation:
Hours at Work:
Days at Work:
Work Phone:
Cell Phone:
Employer's Address:
City
Province
Postal code
Fill out only if applicable
Parent/Guardian with legal custody:
Do you have a decree on file?:
yes
no
Parents are:
Married
Divorced
Seperated
Widowed
Single
Primary Emergency Contact
Full Name:
Relationship to child:
Address:
City
Province
Postal code
Phone:
Cell#
Work#
Secondary Emergency Contact
Full Name:
Relationship to child:
Address:
city
Province
Postal code
Phone:
Cell#
Work#
Person(s) authorized to pick up my child (Besides parents/guardians or emergency contacts)
Person #1:
Person #2:
Person #1:
Daycare references
Has your child ever been in daycare before?:
If so, why did you leave?:
Name of previous provider:
Phone number of previous provider:
Consent to Emergency First Aid & Transportation
I hereby give my permission that my child, may be given emergency treatment by Creative All Stars Childcare I also give permission for my child to be transported by car or ambulance to an emergency center for treatment.
yes
no
Consent to Medical Care & Treatment
In the event that I cannot be contacted immediately, medical or surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician.
yes
no
Consent to Photograph
Consent to Photograph
yes
no
Creative All Stars Childcare will not be responsible for paying for my child's healthcare
Child's Physician:
Phone:
Preferred Hospital:
Phone:
Insurance Company:
Policy Number:
Regular Medications:
Blood Type:
Medicine Allergic to
Food Allergies:
Other Allergies:
Special Health Conditions:
Carecard Number:
Creative All Stars Childcare will not be responsible for paying for my child's healthcare
Number of days per week childcare is needed:
Days of week care is needed:
What time will you bring your child to daycare?:
What time will you pick-up your child?:
For Out of School Care
What School does your child attend?
Email
*
Comments
Agreement
I understand that this is a legally binding document, and have read it and understand it.
yes
no
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