Child Profile Form
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Complete Child Profile Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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___________________
___________________
Registration Date
Start Date
CHILD/FAMILY INFORMATION:
Name of child:_______________________________________________ Male_______ Female________
Date of Birth______________________ Medicare #_______________________Expiry Date__________
Name of Family Physician____________________________________Telephone___________________
Address ______________________________________________________________________________
ALLERGY ALERT:
Please list your child’s allergies
_____________________________
__________________________
________________________
_____________________________
__________________________
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Home Address __________________________________________ Apt #_____City _____________________
Postal Code ___________Phone # _____________ Cell# ______________ Email Address_______________
Mother/Guardian Name ________________________ Father/Guardian Name _________________________
Place of Work (Mother) ____________________________Work Phone # ______________________________
Place of Work (Father) _____________________________Work Phone # _____________________________
Marital Status: Single _____ Married ____ Widowed ____ Separated ____ Divorced _____
With whom has the child lived for most of the past year? Mother ____ Father ____ Both _____
Guardian ___ Other (specify) _________________________________________________________________
Who has permission to pick your child up from the center? _________________________________________
_________________________________________________________________________________________
If changing pick up arrangements parents must inform the center prior to the child being picked up.
Is there anyone who does not have permission to pick your child up from the center? ___________________
_________________________________________________________________________________________
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Parent category: Business