Registration | A Place To Grow

By signing below you acknowledge that you have read, agree, and understand A Place to Grow’s policies and procedures. If you have any questions or concerns regarding the policies or procedures, please address your concerns with the supervisor prior to signing this form so that we may provide clarification.

Caregiver Information

Caregiver 1 Full Name *

Caregiver 1 Sin

Caregiver 1 Address *

Caregiver 1 City *

Caregiver 1 Email *

Caregiver 1 Work Phone

Caregiver 1 Cell Phone

Caregiver 1 Home Phone

Caregiver 1 Employer

Caregiver 2 Full Name

Caregiver 2 Sin

Caregiver 2 Address

Caregiver 2 City

Caregiver 2 Email

Caregiver 2 Work Phone

Caregiver 2 Cell Phone

Caregiver 2 Home Phone

Caregiver 2 Employer

Program Needs

Grade School Your Child Attends

Date You Wish Your Child to Begin Attending

How Did You Hear About A Place to Grow?

Previous Child Care *

If Yes, Where?

Schedule

Is there anyone other than the parents that will be allowed to pick up your child? Please note that we will only release your child to a person listed on this record.

PHOTO I.D IS REQUIRED IF YOUR CHILD IS PICKED UP BY SOMEONE WE DO NOT RECOGNIZE.

Name

Phone

Relationship

Name

Phone

Relationship

Name

Phone

Relationship

In the case of an emergency and the parents cannot be reached, who would you like us to notify?

Name

Phone

Relationship

Name

Phone

Relationship

Developmental History

Child's Health Card Number *

Physician's Name *

Address *

Phone Number *

Does Your Child Have Any Allergies? *

Yes

If Yes, to What?

In the case of ANAPHYLACTIC ALLERGIES additional paperwork is required BEFORE your child may attend the program.

Please Indicate Which Communicable Diseases Your Child Has Had

Other

Has Your Child Had Any Serious Accidents or Illnesses? *

Yes

Details

Has Your Child Ever Been Hospitalized? *

Yes

Details

Does Your Child Have Any Individual or Special Needs? *

Yes

Does Your Child Have Any Food Restrictions? If Yes, Please List

What Arrangements Can You Make for Your Child During Times of Illness?

Does Your Child Have Any Breathing Concerns?

Yes

Details

Personal History

This section to be filled out only if child is infant, toddler or preschool age (under 6 yrs).

Bathroom Habits

Sleeping Habits

Is your child / family receiving services from any of the following?

Service Children First *

Yes

Service Talk To Me *

Yes

Service Summit Centre *

Yes

Service Regional Childrens Centre *

Yes

Service John Mcgivney *

Yes

Service Thames Valley *

Yes

Service Glengarda *

Yes

Service Family Respite *

Yes

Service Childrens Aid Society *

Yes

Please provide us with the contact name and phone number of each company you are working with.

Company Name

Contact Name

Phone Number

Company Name

Contact Name

Phone Number

Company Name

Contact Name

Phone Number

Service Reasons Description

JK/SK/School Age

We ask that you sign the form below allowing A Place to Grow Staff to have open communication with teachers and support staff regarding your child at

School Name *

School. On occasion, as your child's caregiver, we may need to share information about your child's day with their teacher before programming begins, as well as their teacher may need to share information about your child's day with staff. We work very closely with the school to ensure the best for your child.

School Parent Name *

give permission for A Place to Grow staff to have open communication about my child with their school teachers regarding day to day behaviours, illness, programming etc.

School Child Name *

School Date *

Signature *

Child Name *

Signature of Caregiver *

Signature of Caregiver 2

Parent's Consent

I understand that every attempt will be made to contact the parent or guardian in the case of an emergency. However, if they cannot be reached, I give A Place to Grow permission to hospitalize and or seek treatment for my child.

Consent for Walks

During the day the children may be taken off the property to go on supervised walks in the neighborhood and possibly field trips. Do you give permission for your child to participate?

*If the children are taken off the property to go on supervised field trip you will be asked to fill out a separate form stating the place, date and time*

Videotape / Photography

I give permission for the staff of A Place to Grow childcare centre to photograph or videotape my child for the purpose of the children's entertainment and for display within the school.

Zero Tolerance Policy

A Place to Grow childcare has implemented a ZERO TOLERANCE POLICY for any inappropriate, disruptive and/or abusive behavior. A verbal followed by a written warning will be issued as an opportunity to correct behavior. However, if no improvement occurs, immediate dismissal from A Place to Grow will be imminent. Your payment in lieu of a two-week notice will still be required.

I have read and fully understand the entire Parent handbook. I have also completed the enrollment application in FULL and have attached any necessary information. You must have all banking information in Lillio, as well as Reg fee and tech fee paid before your child will be able to start.

Child Registration

Caregiver Information

Program Needs

Schedule

Developmental History

In the case of ANAPHYLACTIC ALLERGIES additional paperwork is required BEFORE your child may attend the program.

Personal History

Bathroom Habits

Sleeping Habits

JK/SK/School Age

Parent's Consent

Consent for Walks

Videotape / Photography

Zero Tolerance Policy