Private Registration Forms for Licensed Home Child Care

Which Child Care Advisor have you been working with? *If you are unsure, please select "I don't know"

Name of Child Care Provider *

Child Care Provider's Address

Child Care Provider's Home or Cell Phone

How many children are you registering? *123

Child #1

Child's Name *

Birthddate *

Home Address *

Name of School

Child #2

Child's Name *

Birthddate *

Home Address *

Name of School

Child #3

Child's Name *

Birthddate *

Home Address *

Name of School

Parent/Guardian Contact Information

Parent/Guardian #1

Parent/Guardian's Name *

Home Address *

Home or Cell Phone *

Email *

Work/School *

Work or School Phone *

Parent/Guardian #2

Parent/Guardian's Name

Home Address

Home or Cell Phone

Work/School

Work or School Phone

Emergency Contacts

Please list TWO (2) persons to whom the children may be released if the parents/guardians are unavailable due to an emergency.

We recommend asking the following people:
- Friends
- Neighbours
- Extended family (the child's grandparents, aunts, cousins etc.)
- Pastors
- Teachers
- Colleagues

Emergency Contact #1

Name *This person CANNOT be the parent/guardian.

Home Address *

Home Phone *

Cell Phone *

Emergency Contact #2

Name *This person CANNOT be the parent/guardian.

Home Address *

Home Phone *

Cell Phone *

Other persons the child(ren) may be released to

Please name anyone else who may pick up the child/ren.

Name

Cell Phone

Name

Cell Phone

Medical Information

Medication Acknowledgement *

I understand that any prescription or non-prescription medication with a Drug Identification Number (DIN) must be supplied in its original container. I understand it must be labelled with the child's name, dosage and storage instructions. I understand it may only be administered by the provider if I have given written authorization (e.g. sunscreen, diaper creams, Tylenol, Restolax).

Are your child's immunizations up to date? *YesNoImmunization Records or Proof of Exemption required.

Child 1: Date of Tetanus Shot *

If your child is under 2 months old, and has not yet received their first round of vaccinations, please put the date of their upcoming appointment.

Child 2: Date of Tetanus Shot *

If your child is under 2 months old, and has not yet received their first round of vaccinations, please put the date of their upcoming appointment.

Child 3: Date of Tetanus Shot *

If your child is under 2 months old, and has not yet received their first round of vaccinations, please put the date of their upcoming appointment.

Please upload proof of immunization for each child who does not attend school. *

For example, a high quality photo, or scanned copy of your child's immunization booklet.

Allowed formats include JPG, JPEG, PNG, PDF. Maximum 8MB per file.

Please upload proof of exemption. *

For a medical exemption, you will require a Statement of Medical Exemption to be completed by your child's physician.

For a non-medical exemption, or a conscience or religious belief exemption, you will need to complete the Instruction Form: Statement of Conscience or Religious Belief. You will also need a Statement of Conscience or Religious Belief to be signed by a Commissioner for Taking Affidavits.

Allowed formats include JPG, JPEG, PNG, PDF. Maximum 8MB per file.

Do any of these children have any special needs? *YesNoIf yes, you may be required to complete the Individual Support Plan for Special Needs.

Do any of these children require regular medication, medical treatments or procedures (e.g. for allergies, seizures, intolerances or asthma)? *YesNoIf yes, you may be required to complete the Individual Support Plan for Medical Needs.

Do any of these children have any potentially life-threatening allergies (anaphylactic allergies)? *YesNoIf yes, you may be required to complete the Anaphylaxis Alert and Permission Form

Please list your child(ren)'s allergies: *An Anaphylaxis Alert and Permission Form may be required. Please contact your Child Care Advisor.

Have any of these children ever had chronic health problems, or had any communicable diseases? *YesNo

You answered yes to one or more of the above medical questions. Please describe: *

Please describe the general health of your children: *

Do any of these children have any special dietary or feeding arrangements? *YesNo

You answered yes to the above question. Please describe: *

Special Feeding Instructions (Under 1 yr old)

Food and/or Drinks *

I understand that any food or drinks my child brings from home must be labelled with their name.

How often would you like the provider to check on your children while they're napping? *Every 15 minutesEvery half hourEvery hourNot applicable/No nap.

Hours of Care

Drop Off Time *Please enter the earliest time you will drop off.

Pick Up Time *Please enter the latest time you will pick up.

Weeks care is required: *Ongoing/PermanentTemporary

First Day of Care *

The first day you expect care to commence

Last Day of Care *

The first day you expect care to commence

Parent Responsibilities *

As a private parent attending this licensed day care home, I agree to the terms and conditions the provider has outlined, the requirements of the Children’s Village of Ottawa - Carleton Licensed Home Child Care Program and those under the Child Care and Early Years Act, (CCEYA), 2014. I agree to the hours and days of child care as indicated above.

Parent/Guardian Signature *

This certifies all provided information is correct to the best of your knowledge.

Date *

Child #1

Child #2

Child #3

Parent/Guardian Contact Information

Parent/Guardian #1

Parent/Guardian #2

Emergency Contacts

Emergency Contact #1

Emergency Contact #2

Other persons the child(ren) may be released to

Please name anyone else who may pick up the child/ren.

Medical Information

Hours of Care

Address & Phone

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