Daycare Registration | Pink Elephant

Child Information

Child's Name*

First Last

Address*

Street Address Postal Code

Birth Date*

MM slash DD slash YYYY

Parent/Guardian 1 (mother)

Guardian's Name*

First Last

Address*

Street Address Postal Code

Cell Phone*

Work Phone*

Email*

Parent/Guardian 2 (father)

Guardian's Name

First Last

Address

Street Address Postal Code

Cell Phone

Work Phone

Emergency Contact 1

Emergency Contact Name*

First Last

Address*

Street Address Postal Code

Cell Phone*

Relationship to Child*

Emergency Contact 2

Emergency Contact Name*

First Last

Address*

Street Address Postal Code

Cell Phone*

Relationship to Child*

People Authorized to Pick Up Child from Centre

Authorized Person 1

Authorized Pickup Person Name*

First Last

Address*

Street Address Postal Code

Cell Phone*

Relationship to Child*

Authorized Person 2

Authorized Pickup Person Name*

First Last

Address*

Street Address Postal Code

Cell Phone*

Relationship to Child*

Medical Information

Physician's Name*

First Last

Clinic*

Any Allergies or Medical Concerns?*

Alberta Health Care Number*

Any Physical Disabilities?*

Any Emotional/Behavioural Problems?*

List any Surgery, Fractures, or Maladies your child has had:*

Immunization Record

Please upload your child's immunization record

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 300 MB, Max. files: 2.

Permission Forms

Government regulations regarding safety and security for both the Centre and the child require parental permission to process a number of activities (schedule and unscheduled).

1. Sibling Release permission
2. Re-location Permission
3. Medical Disclaimer Permission
4. Field Trip Permission
5. Morning Outside Play Permission (only for OSC)
6. F.O.I.P release Permission

Sibling Release Permission*

I give permission for my child to be released from Daycare or OSC program to his/her brother or sister. I understand that the Centre’s liability for my child ends when the sibling takes child out of the program.

Re-Location Permission*

I give permission for my child listed previously to use Archbishop O ‘Leary High School as a site for relocation in case of emergency.

Medical Disclaimer Permission*

In the event that my child should have a sudden illness or accident at the Center I understand that the staff will try to reach me for instructions. If emergency treatment is needed, I request that the assistance be requested from Paramedics and I consent to any emergency treatment that is recommended by them and/or Hospital Emergency room personnel. It is understood that every effort will be made to contact the undersigned before treatment but that emergency treatment will not be withheld if I cannot be reached. It is also understood that I will be responsible for all costs in the treatment of the child.

Field Trip Permission*

Children participate in walks and trips outside the Center’s premises or the school building and playground. Notification will be given prior to each field trip being conducted. I give permission for my child to attend walks and trips outside the Center’s premises.

Morning Outside Play Permission (Only OSC)*

I give permission for my child to leave the Center to play outside prior to school commencing in the morning. I understand the Center is not responsible for activities that might occur while not in the direct care of the Center staff.

F.O.I.P. Release Permission (Freedom of Information and Protection of privacy Act)*

The following items describe activities where student information may be used. Please read carefully and complete the consent section on the following page. The following items describe activities where student information may be used. By giving your consent to the particular sections you are allowing the use of information and materials only within the Centre. No materials and information will be released outside without signing a separate permission form.

Pink Elephant Childcare Society Activities Consent List

Communications*

The use of the child’s name and/or video in a calendar, newsletter, scrapbook, and concert program publication/communication.

Yes

Centre Purposes*

The taking and use of individual, group, team or centre video/photos within the centre community or centre purposes.

Yes

Child work*

The use of the child’s name on artwork, written material, or other creative work/material to be displayed at the centre.

Yes

List*

The use within the centre of the child’s name on group lists, ceremonies, concerts and other events.

Yes

Birthday*

The use of the child’s name for birthday recognition purposes.

Yes

Media*

The taking of photos/video of room or centre activities, and their use be media where students are not identified by name. (Before the media identifies and individual child, a media consent for will be completed by the parent/guardian.)

Yes

Other*

Other similar activities within the Pink Elephant Childcare Society community.

Yes

Daycare Feedback

How did you find out about the facility?

Why did you choose this facility?

Contract Signatures

If a client fails to live up to this contract, or any of the agreements made therein, Pink Elephant Childcare Society may pursue court action and will pursue garnishment of wages to recover unpaid fees. All cost that incurred, that is NFS cheques, interest charges and court costs will become the responsibility of the client.

Parent Handbook Acknowledgement*

I have read and understand the Parent Handbook above, and I agree to abide by the policies in place.

Parent Orientation Acknowledgement*

I acknowledge I will be required to participate in a Parent Orientation prior to my child joining the program. (Pink Elephant will reach to you to set up a time)

Casino Acknowledgement*

I understand I (or one representative from my household) will be required to volunteer one Casino fundraising shift (every 2 years), otherwise, a payment of $200.00 will be incurred for not participating.

Contract and Policies Aknowledgement*

I have read this contract in its entirety, and I agree to abide by the policies in place.

Parent/Guardian Name

First Last

Signature*

This field is for validation purposes and should be left unchanged.

Ready to Register?

Registration Form

Child Information

Parent/Guardian 1 (mother)

Parent/Guardian 2 (father)

Emergency Contact 1

Emergency Contact 2

People Authorized to Pick Up Child from Centre

Authorized Person 1

Authorized Person 2

Medical Information

Permission Forms

Pink Elephant Childcare Society Activities Consent List

Daycare Feedback

Contract Signatures