Specialized Childcare Registration

Please fill in 1 form per child

Registration Form

Childs First name

Childs Last name

Date of Birth

Year

Month

Day

Upload Current Photo of Child

A clear photo of your child's face please.

Address

Phone

Gender

Required to select one option for childcare licensing regulations.

List Allergies, Medical Conditions, Extra supports your child requires

Staff will reach out if we need further clarification to ensure that we have appropriate staffing for your child to succeed. We strive to be inclusive for all.

Is y our child immunized?

Keeping record of your child's immunization status on file is part of childcare licensing, please select the option most applicable.

Doctors Name and Phone Number

If you do not have a family doctor, please indicate what urgent care/walk in/emergency room you would use and their phone number or write 9-1-1

MSP Number (Medical Care Number)

If you are from another province please indicate what province.

By checking this box I authorize the staff of the family centre, MFRC to preform first aid on my child while in attendance of our programs. If Staff deem required I understand that seeking help from other medical professionals and/or ambulance will be called at the expense of the caregivers.

Caregiver 1 Name

Phone

Caregiver 2 Name

Phone

Email for Caregiver(s)

Which situation suits your family best?

Emergency Contacts MUST be different than above caregivers and are required. If you are new to the area you can use neighbours or co-workers who may know how to get a hold of you.

Emergency Contact 1

Phone

Can pickup child?

Emergency Contact 2

Phone

Can pickup child?

List any persons NOT permitted to pickup your child

Please note we legally can not hold a child from a biological parent without a court order on file.

Date of Enrollment

Year

Month

Day

Today's Date

Specialized Childcare Registration

Registration Form

Fill out your Privacy and Confidentiality Consent Form Remplissez votre formulaire de consentement à la confidentialité et à la protection des données personnelles.

Fill out your Privacy and Confidentiality Consent Form
Remplissez votre formulaire de consentement à la confidentialité et à la protection des données personnelles.