Registration

Guardian or Parent 1

Name *

First

Last

Email *

Home Phone

Cell Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Work Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Guardian or Parent 2

Name *

First

Last

Email *

Home Phone

Cell Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Work Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Contact

Name *

First

Last

Address

Phone

Relation to Child

Authorized for Pickup

Yes
No

Child Infomation

Name *

First

Last

Birth Date

Sex

Male
Female

Child Lives With

Mother
Father
Other

Desired Start Date

Program

Full Time
Part Time
Drop In

Medical

Health Care #

Physician's Name *

First

Last

Physician's Phone

Medical Concerns

Diet Restrictions

Allergies

Is the child's immunization up to date?

Yes
No

Does your child receive medication on an ongoing basis?

Yes
No

If yes, please specify

Copy of Health Care Card

Copy of Immunization Records

Other

How did you hear about us?

I understand the contents of the Parent Handbook and the Policies of the centre.

I provide informed consent for the developmental checklist.

I consent to the use of photographs and videos containing my child in Little Angels public communications.

Little Stars

Guardian or Parent 1

Guardian or Parent 2

Emergency Contact

Child Infomation

Medical

Other

Get Your Child Started Today

Get Your Child
Started Today