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Before and After School Care Information Form

A form that collects information about children, parents or guardians, and emergency contacts needed to enroll them in a before- and after-school care program.

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Child Information

1st Child's Name:*

Nombre

Apellido

Gender:*

Male Female

Date of Birth:*

Consent*

I agree to the program terms for this child

2nd Child's Name:

Gender:

Male Female

Date of Birth:

Consent

I agree to the program terms for this child

Please add additional children here:

Mother's Name:

Mother's Email:

Mother's Cell Phone:

Mother's Home Phone:

Mother's Business Phone:

Father's Name:

Father's Email:

Father's Cell Phone:

Father's Home Phone:

Father's Business Phone:

Please state any shared custody arrangement, if applicable:

Child's Primary Address:

Dirección

Ciudad

Estado / Provincia

Código postal

Are you new to Canada?*

Yes No

If yes, where are you from:

How long have you been in Canada?

First Language Spoken at Home:

Second Language Spoken at Home:

Do your children have any health issues? If so, please describe:

Do your children have allergies? If so, list them here.

Do your children have any physical, social, or emotional challenges we should be aware of? If so, describe here:

Emergency Contacts

First Emergency Contact's Name*

Nombre

Apellido

Authorized for Pick-ups*

Yes No

Relationship to Child:*

Cell Phone:*

Home Phone:

Second Emergency Contact's Name*

Nombre

Apellido

Authorized for Pick-ups*

Yes No

Relationship to Child:*

Cell Phone:*

Home Phone:

Other Authorized Pick-ups

Name

Nombre

Apellido

Relationship to Child:

Phone Number

Name

Nombre

Apellido

Relationship to Child:

Phone Number

Please list others authorized to pick up the child here:

Is your child also attending Tykes N Tots Daycare at Cardinal Leger School?

Yes No

Please provide any further information about your child that would help us understand and care for them:

Authorization

I declare that the information provided is true and complete.

Date

Signature

Sign here

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