Registration

Please complete this form and one of our representative will contact you shortly.

1/9Registration Page

Date of birth:
 

2/9Please fill with additional info

3/9Parent(s) / guardian(s):

4/9

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):
If appropriate, list an English speaking contact:
 

5/9 Has the child previously attended daycare/preschool?

Comments/instructions to help us care for your child. (Please feel free to add additional pages.):
 

6/9 HEALTH INFORMATION:

Health professionals involved with your child (other than doctor and dentist):
Does your child have: A medical condition/concern?
Allergies?
Asthma?
Has your child had a seizure in the past year?
Does your child require a special diet related to a medical condition?
Food sensitivities?

7/9List all prescription and “over the counter” medications your child receives:

8/9Health Information (CONTINUE)

You may be asked to complete additional forms if you answered yes to any of the above.
The above health information may be made available to the staff of Vancouver Coastal Health.


Custody Agreement:
Provided to Facility:
Photocopy of Immunization Records Provided to the Facility:
 

9/9Send an optional message

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