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Kids pointe Daycare

Child's Information: *
Child's Information: *
Address:*
Phone Number: *

Parent's Information

Mother's Name:*
Father's Name:*
Mother's Address: *
Father's Address: *
Mother's mobile number:*
Father's mobile number: *
Mother's Email: *
Father's Email: *
Place of Work
Place of Work
Occupation:
Occupation:
Work Address:
Work Address:
Work Number:*
Work Number:*

Emergency Contacts

2 Contacts Required

Primary Contact:*
Secondary Contact:*
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Address *
Address *
Phone Number*
Phone Number*
Email: *
Email: *

Authorized to Pick Up Child:

Person 1:
Person 2:
Address
Address
Phone Number*
Phone Number*

Daycare Requirements

What days of the week do you require childcare?:
Program/Care Required:
Subsidy Applied For?: *
Subsidy Amount:*
Preferred Payment Method:

Health and Medical Information

Alberta Health Care Number:
Doctor's Name:
Doctor's Office Address:
Dr. Office Phone:
Immunization Records:
Does your child have any disability or special needs?:
If yes, please provide more information:
Does your child take any medication on an ongoing basis?:
If yes, please provide more information about medical condition and medication:
Has your child had any major operation?:
Please provide details of major operation:
Do you have concerns about your child's development?:
Please list any allergies and signs and symptoms associated with a reaction:
Does your child have any special behaviours or habits we should be aware of?:

Family Information

Marital Status:
Siblings:
Please provide details of custody arrangement (if any) we should be aware of:
Any special cultural celebrations at home?:

Parent/Legal Guardian Consent and Agreement - Medical

As the Parent/Legal Guardians), I give consent to have my child receive first aid care by the staff of Kids Pointe Daycare & OSC. I/We understand that medication will only be administered to my child only if a Medication Administration form has been filled out by me. If this form is not filled out, I will be responsible for administering my child's medication. All medications must have the pharmacy label attached and staff will only follow the directions of the label, which should match the medication administration form. We store medications in a secure box (refrigerated and non-refrigerated) that will be located within the child's room (refrigerated medications will be kept in the closest fridge in a lockbox). If a medical emergency requires staff to call Emergency Medical Services (9-1-1), all costs not covered by insurance will be the sole responsibility of the child's parent/guardian. I give responsibility to my emergency contact person to act on my behalf until I am available. I also understand the importance and will ensure all contact information will be updated immediately if there are changes. I also agree to review this information every six months.