Name of Facility CHILD'S STARTING DATE:(Required)Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Sex(Required) Male Female DATE OF BIRTH:(Required)Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031NAME OF CHILD:(Required) Name the Child responds to: Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone:(Required)Person(s) with whom the child lives (adults and children): Child's first language: Other languages: Parent(s) / guardian(s):Name:(Required) Home phone:(Required)Cell phone:(Required)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:(Required) Relationship to child:(Required) Home phone:(Required)Work phone:Cell phone:(Required)Name:(Required) Relationship to child:(Required) Home phone:(Required)Work phone:Cell phone:(Required)Name: Home phone:Work phone:Cell phone:Name: Home phone:Work phone:Cell phone:If appropriate, list an English speaking contact:Name: Phone:Has the child previously attended davcare/preschool?(Required) YES NO Comments: Comments/instructions to help us care for your child. (Please feel free to add additional pages.):Toileting/Diapering (special words): Rest Time (special comfort – toy/blanket): Eating/Mealtime (include food likes/dislikes): Fears: Please tell us anything else you think will help us provide an enriching experience for your child: HEALTH INFORMATIONHealth 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?(Required) YES NO If yes, please provide further information: Allergies?(Required) YES NO If yes, please provide further information: Asthma?(Required) YES NO If yes, please provide further information: Has your child had a seizure in the past year?(Required) YES NO If yes, please provide further information: Does your child require a special diet related to a medical condition?(Required) YES NO If yes, please provide further information: Food sensitivities?(Required) 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 You may be asked to complete additional forms if you answered yes to any of the above.This health information may be made available to the staff of Creative Day CareCustody Agreement YES N/A Provided to Facility YES NO N/A Immunization Documents Returned to Facility YES NO Information Provided By:Name Print Name SignatureMax. file size: 2 MB.SignatureDateYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031DateInformation Received By:Name Print Name SignatureMax. file size: 2 MB.SignatureDateYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Date
