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Facilities Licensing Childcare Registration

Name of Facility
CHILD'S STARTING DATE
SEX
  Male   Female
DATE OF BIRTH
Child's Surname:
Child's Given Names:
Also Known As:
Name the Child responds to:
Address:
Postal Code:
Phone:
Person(s) with whom the child lives (adults and children):
Child's first language:
Other languages:

Parent(s) / guardian(s):

Name:
Home phone:
Cell phone:
Work phone:
Days/hours of work:
E-mail:
Name:
Home phone:
Cell phone:
Work phone:
Days/hours of work:
E-mail:

Person(s) authorized to pick up the child and be contacted in case of emergency. These people should be available during hours of care. (include mother / father / guardian):

Name:
Relationship to child:
Home phone:
Work phone:
Cell phone:
Name:
Relationship to child:
Home phone:
Work phone:
Cell phone:
Name:
Relationship to child:
Home phone:
Work phone:
Cell phone:
Name:
Relationship to child:
Home phone:
Work phone:
Cell phone:

If appropriate, list an English speaking contact:

Name:
Phone:

Has the child previously attended daycare/preschool?

  Yes   No Comments:

Comments/instructions to help us care for your child:

Toileting/Diapering (special words):
Rest Time (special comfort – toy/blanket):
Eating/Mealtime (include food likes/dislikes):
Fears:

HEALTH INFORMATION

Health professionals involved with your child (other than doctor and dentist):
Name:
Profession/Agency:
Phone:
Name:
Profession/Agency:
Phone:
Name:
Profession/Agency:
Phone:

Does your child have:

A medical condition/concern? Yes   No
If yes, please provide further information:
Allergies? Yes   No
If yes, please provide further information:
Asthma? Yes   No
If yes, please provide further information:
Has your child had a seizure in the past year? Yes   No
If yes, please provide further information:
Does your child require a special diet related to a medical condition? Yes   No
If yes, please provide further information:
Food sensitivities? Yes No
If yes, please provide further information:

List all prescription and “over the counter” medications your child receives:

Medication:
Times Given:
Reason for Medication:
Medication:
Times Given:
Reason for Medication:
Leave this empty:

You may be asked to complete additional forms if you answered yes to any of the above.