bright horizons childcare registraion form · contact all my emergency contacts will result in the...
TRANSCRIPT
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#5 Spruce Village Way, Spruce Grove, AB T7X 0B2
!Phone#:!780:478:2273 ex. 3!!!Email:[email protected]!
www.bhchildcare.ca7 7
!Child’s!Name:! ! ! ! ! ! !Nicknames:! ! ! ! ! !
Birth!Date:! ! ! ! ! ! !Age:! ! ! ! !M / F ! !
Child’s!Address:!! ! ! ! ! ! ! ! ! ! ! !
School!(if!applicable):! ! ! ! ! ! ! Grade:! ! ! ! !
Parent/7guardian7information7#17 Parent/7guardian7information7#27Relationship!to!child:!!
Relationship!to!child:!
Name:!!
Name:!
Address:!!
Address:!
City/postal!code:!!
City/postal!code:!
Email:!!
Email:!
Home!#:!!
Home!#:!
Cell!#:!!
Cell!#:!
Employer7information7 Employer7information7Place!of!work:!!
Place!of!work:!
Address:!!
Address:!
Work!#:!!
Work!#:!
Emergency7contact7person7 Emergency7contact7person7Relation!to!child:!!
Relation7to7child:77
Name:!!
Name:77
Address:!!
Address:7
Work!#!!
Work7#7
Home!#!!
Home7#7
Cell!#!!
Cell7#7
Preferred Start Date: _____________FULL TIME / PART TIME (circle one)Preferred Days: M T W TH F
MEDICAL7INFORMATION7
Child!health!care!#:!!Physician!name:!!Physician!#:!!Type7of7Allergies/7medical7conditions:77Reaction:77Recommendation7to7avoid:77Emergency7instructions:77Is7child7aware7of7allergy/7medical7condition? Yes / No 7State!any!dietary!restriction:!!State!child’s!typical!reaction!to!illness:!!Persons7 authorized7 to7 pick7 up7 child:! Please! note! that! you! are! authorizing! these! persons! to! pick! up! your! child! at!anytime!and!on!any!day,!without!the!center!requiring!prior!parental!consent.!If you would like to add an additional personfor a one time use pickup, please ensure you let the office staff know via email or letter. Please!ensure!that!anyone!coming!to!pick!up!your!child!has!proper! identification!(photo! id)!or!the!center!will!be!unable!to!release!your!child.!
Name77 Relationship7to7child7 Parent7initial7!
1. !! !
!2. !
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!3. !
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!4. !
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!5. !
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Bright7Horizons7Regulation7Agreement77
1) Bright!Horizons!hours!of!operation!are!6:30am:6:00pm,!Monday!to!Friday.!
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2) I!agree!to!pay!Center!fees!on!the!1st!of!each!month!for!that!month.!I!understand!the!person!registering!
the!child!to!center!is!responsible!for!fees.!I!understand!that!a!late!fee!of!$10.00!per!week!will!be!added!
to!the!fees!for!late!payments.!I!understand!that!if!the!center!fees!are!not!paid!the!center!reserve!the!
right!to!use!a!collection!agency!and!/!or!legal!means!in!which!to!collect!the!fees!owing.!I!understand!
the!onus!for!the!center’s!cost!for!collection!or!lawyer!fees!will!on!the!parent!or!guardian!of!the!child.!!
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3) I!agree!that!obtaining!and!maintaining!subsidy!for!my!child!(ren)!is!my!responsibility.!If!at!any!time!my!
fees!are!not!subsidized!for!whatever!reason!I!will!be!responsible!for!the!full!center!fee.!
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4) I!agree!that!if!I!arrive!after!the!centers!daily!closing!time,!it!is!my!responsibility!to!pay!the!late!fee!of!
$1.00!per!minute!per!child.!I!am!also!aware!that!failure!to!pick!up!my!child!from!center!after!closing!
hours!without notification to center about being tardy and after the center has tried without success tocontact all my emergency contacts will result in the center contacting child services to collect mychild(ren).
Are7child7immunizations up to date? Yes / No 7
5) I!agree!to!pay!for!center!field trips,!special!activities!and!supplies!if!a!fee!is!charged!for!these!activities.!I!understand!that!I!will!need!to!sign!a!permission!slip!and!have!fees!paid!prior!to!my!child!attending!offsite!
activities.!I!am!aware!that!I!am!responsible!for!arranging!alternate!care!for!the!duration!of!the!off:site!
activity!if!I!have!not!paid!the!fee!or!signed!permission!slip.!!
6) The!center!agrees!to!use!all!due!care!in!caring!for!all!children!&!their!belongings!left!within:!however!the!
center!will!not!be!liable!for!any!loss!of,!damage!to,!clothing!or!other!belonging!of!children!while!in!center!
care.!
7) If!child!is!going!to!be!absent!or!late!from!center,!the!center!is!to!be!informed!immediately.!
Acknowledgements7&7consent7
7Termination7of7services7–7I!acknowledge!that!the!center!reserves!the!right!to!terminate!child!care!services!at!any!
time!if!the!center!policies!or!procedures!are!violated.!!!
Off7premise7permissionQ7I!give!permission!for!the!center!to!take!my!child!off!the!premises!during!the!course!of!
daily!activities.!This!includes!neighbourhood!walks!and!walking!to!visiting!nearby!parks!and!playgrounds.!!
First7aid7permissionQ7I!give!permission!for!the!center!to!administer!any!first!aid!they!deem!necessary!following!
center!medical!policies!and!procedures.!I!also!give!the!center!permission!to!phone!for!an!ambulance!as!the!
situation!demands!and!I!will!be!responsible!for!any!cost!incurred.!
Transportation7permissionQ7I!give!permission!for!the!center!to!transport!my!child for field trips.!!
Photograph7permissionQ7I!give!permission!for!the!center!to!display!children’s!pictures,!art!and!craft,!allergy/
dietary!restrictions!list!etc.!I!also!allow!the!center!staff!to!take!pictures!(camera,!video!camera,!etc)!of!my!child!
for!the!purpose!of!display!around!the!center.!The!center!will!use!these!items!in!the!center!accreditation!
processes!as!well.!!
Custody Orders- I agree to provide the center with the most up to date custody or parenting order (if one is in place). The ensure the safety and wellbeing of my child.
Child7safetyQ7I!understand!that!the!center!will!take!every!precaution!and!care!to!insure!my!child’s!safety.!Center!
staff!will!provide!proper!supervision!and!will!exercise!every!precaution!to!avoid!accidents!or!incidents.!In!
understanding!this!I!do!not!hold!the!center!liable!for!any!accident,!incident!or!illnesses!that!occur!while!in!center.
I7agree7and7am7bound7by7the7terms7stated7in7this7registration7form7and7I7realize7that7I7can7talk7to7the7 center7if7I7have7any7concerns7before7signing7the7registration7form.7
Parent7signature:! ! ! ! ! ! ! Date:! ! ! ! !
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For7office7use7only7
Date!of!registration:! ! ! ! !!!!!!!!!!!!!!!!!!!!!!!!!!Tour!of!center:! ! ! ! ! !
First!attendance!date:!! ! ! ! !!!!!!!parent!handbook:!! ! ! ! !
Subsidy:! ! ! ! ! !!!!!!!!!!!!!!!!!!!!!!!!!Legal!Custody/!Court!order:! ! ! ! !