Registration Date

End Date

Child's Name: *

First

Last

Date of Birth: *

Gender: *

Male
Female
Other

Age: *

Grade: *

(In September)

Child lives with: *

Parents
Mother
Parent
Guardian

Mailing Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent/Guardian #1: *

Primary Phone Number: *

Secondary Phone Number:

Work Phone Number:

Place of Employment:

Email Address: *

Add another Parent/Guardian? *

Yes
No

Does your child identify as an Indigenous Person or other racialized community? *

Yes
No

Child Access

Can an adult, other than the parent(s)/guardian(s), pick up your child? *

Yes
No

Is there any person(s) who CANNOT access your child? *

Yes
No

Emergency Contacts

Emergency Contact Name: *

First

Last

Friends or relatives who are NOT living in the same house as child (At least 1 is REQUIRED by Licensing)

Relationship to child: *

Primary Phone Number: *

Secondary Phone Number:

Work Phone Number:

Add another emergency contact? *

Yes
No

I, *

First

Last

give permission to the above mentioned adults to assume responsibility for my child in the event of an emergency

Health History

Doctor. If you don't have a doctor, please put walk-in or emerg: *

First

Last

Doctor's Phone:

Care Card #: *

Immunizations up to date? *

Yes
No

Allergies/Asthma? *

Yes
No

Layout

Special Needs/Medical Disability? *

Yes
No

Layout

Layout (copy)

Is there Medication staff will need to give your child? *

Yes
No

Layout

Does your child have a Behaviour Plan in place? *

Yes
No

Special Comments/Instructions:

Photo and Description

Photo: *

Hard copy
Digital copy

Layout

Height: *

Weight: *

Eye Color: *

Hair Color: *

Identifying Marks (if any):

Permission To Use Picture

I,

First

Last

, the parent/guardian of child/children participating in Whitevalley Community Resource Centre programs (Hereinafter known as WCRC), agree to the following:

With my signature below I grant permission for my child(ren) whose name(s) are listed below may be photographed at the programs and I understand that these photographs may be used in promoting our organization and services or by program funders, either in print or on the Internet. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses. I agree that this form will remain in effect during the term of my child’s enrollment. I understand that there will be no payment for me or my child’s participation in this release.

Child is known as:

First

Last

Relationship to Child:

Cherryville Kids Zone will operate Monday AND Thursday; November to March. The Program will be closed over Winter and Spring Break. Payment is REQUIRED prior to your child's (ren) attendance. In the space below, please indicate which day or days you want your child to attend. *

Consent

1. In case of an emergency, I hereby give permission to the staff to call a doctor or ambulance in the event of an accident or illness involving my child and to release my child to someone other than the parent. I will be responsible for the costs *