Form Overview Provide form overview here. Which Child Care Advisor have you been working with? *Please select your Child Care Advisor...KatyeMargaretMeganRebeccaSandra CarquezSandra ZitoI can't rememberIf you have not been contacted by a Child Care Advisor yet, please select 'No Assigned Advisor'.Child InformationPlease complete all required fields for your child.Personal Data Consent *I agree to provide all personal and medical information for my child and to have this information kept on the premise where care is being provided and at the Children’s Village head office. Child's First Name *Child's Last Name *Languages Spoken at Home and School *Birthddate *Home Address *Program / Age *Please choose...Infant (Up to 18 months)Toddler (18 months - 2.5 years)Preschool (2.5 years - 4 years)Kindergarten (4 years - 5 years)School (6+ years)Does your child attend school? *YesNoName of School *Grade *Are there any custodial arrangements or restrictions on your child? *YesNoPlease describe the custodial arrangements or restrictions on your child. *Specify the name of the person, their relationship to your child, and any schedules that you adhere to. Supporting documents may be required.Parent/Guardian Contact InformationPlease complete all required fields for your parents and/or guardians..Parent/Guardian #1Parent/Guardian's First Name *Parent/Guardian's Last Name *Home Address *Home Phone *Cell Phone *Email *Work/School Name *Work/School Address *Work/School Phone *Enter your work/school phone number followed by your extension number, if applicable.Parent/Guardian #2Parent/Guardian's First NameParent/Guardian's Last NameHome AddressHome PhoneCell PhoneEmailWork/School NameWork/School AddressWork/School PhoneEnter your work/school phone number followed by your extension number, if applicable.Emergency ContactsPlease list TWO (2) persons to whom the children may be released if the parents/guardians are unavailable due to an emergency. Emergency Contact #1First Name *This person CANNOT be the parent/guardian.Last Name *Relationship to Child *Home Address *Home PhoneCell Phone *Work PhoneEmergency Contact #2First Name *This person CANNOT be the parent/guardian.Last Name *Relationship to Child *Home Address *Home PhoneCell Phone *Work PhoneMedical InformationPlease complete all required fields.Medication Acknowledgement *I understand that any prescription or non-prescription medication with a Drug Identification Number (DIN) must be supplied in its original container, and may only be administered by the provider if I have given written authorization (e.g. sunscreen, diaper creams, Tylenol, Restolax).Doctor's Name *If you do not yet have a family doctor, you may use the nearest Appletree Medical Clinic.Doctor/Clinic Phone *Doctor/Clinic Address *Ontario Health Insurance Plan (OHIP) NumberAre your child's immunizations up to date? *YesNoImmunization Records or Proof of Exemption required.Please upload proof of immunization for each child who does not attend school. *Choose FileNo file chosenDelete uploaded fileFor 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. *Choose FileNo file chosenDelete uploaded fileFor 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.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.Does your child have any potentially life-threatening allergies (anaphylactic allergies)? *YesNoPlease list your child's allergies:An Anaphylaxis Alert and Permission Form may be required. Please contact your Child Care Advisor.Does your child 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.Has your child ever had chronic health problems, or had any communicable diseases? *YesNoYou answered yes to one or more of the above medical questions. Please describe: *Please describe your child's general health: *Behaviour & Learning NeedsPlease complete all required fields.Have there been any recent family changes (new baby, separation, move etc.)? *YesNoYou answered yes to the above question. Please describe:Does your child have any behaviour concerns? *YesNoDoes your child have any special learning needs? *YesNoDoes your child have any fears? *YesNoDoes your child have any reaction to separation? *YesNoDoes your child have any speech/language concerns? *YesNoDoes your child have any motor development concerns? *YesNoYou answered yes to one or more of the above behaviour and learning needs. Please describe it, and how it is managed: *An Individual Support Plan for Special Needs may be required. Please contact your Child Care Advisor.0 / 120Eating, Sleeping, and Toileting HabitsPlease complete all required fields.Does your child have any food restrictions, special diets, or preferences? *YesNoYou answered yes to the above question. Please describe: *Food and/or Drinks *I understand that any food or drinks my child brings from home must be labelled with their name.Sleep Policy Acknowledgement *I have read and understand the sleep policy, as outlined in the Home Child Care Parent Handbook.Number of naps per day:How often would you like the provider to check on your child while they're napping? *Every 15 minutesEvery half hourEvery hourNot applicable, my child does not nap.Please describe any nap restrictions, comfort items, how the room is set up, etc.:0 / 70Toilet habits & routines *Uses the bathroom independentlyToilet trainingIn diapersPlease describe your child's toilet habits, routines, etc.For example, elaborate on timing (goes potty before/after naps or lunch), specify the type of diapers (cloth diapers only, no Huggies, etc.), or indicate sensitivity to specific products, etc.0 / 100Hours of CarePlease complete all required fields.Please note that Special Rates must be approved in advance for care: Before 6:30 a.m. After 6:00 p.m. More than 10 hours per day On weekends Which days do you require care? *MondayTuesdayWednesdayThursdayFridaySaturdaySundayIt Varies / Shift WorkPlease describe your varied hours/shift work: *Start Date *The first day you expect care to commenceDrop Off Time *Hours120102030405060708091011Minutes00153045AMPMPick Up Time *Hours120102030405060708091011Minutes00153045AMPMDrop Off Time *Please enter the earliest time you will drop off.Pick Up Time *Please enter the latest time you will pick up.Handbook AcknowledgementPlease complete all required fields.If you haven't already done so, please take the time to read the Home Child Care Parent Handbook (PDF)I consent to my child being placed in a home with pets. *YesNoAdmission and Discharge Policies *I understand the admission and discharge policies.Fee Policies *I understand the fee policies.Agency Policies *I have read and understand all other policies outlined in the Agency Parent Handbook.Parent Handbook *I acknowledge that I have read the Agency Parent Handbook and understand all the requirements and responsibilities of parents using the service and agree to abide by the terms and conditions thereof. Failure to do so may result in termination of care. I understand that the Agency is a Licensed Home Child Care Agency, and as such has made every effort to fulfill the requirements of the Child Care and Early Years Act. I understand the Agency is not liable for the actions of the Provider.Limitation of Liability *I understand and agree that the Child Care Provider and Children’s Village of Ottawa-Carleton will have no liability to the parent/guardian or any other party for any loss or damage to personal property (whether direct, indirect, or consequential) which may arise from the provision of services. For this reason, Children’s Village encourages families to keep valuables, such as electronic devices, safely at home.Information Accuracy *I understand that the Child Care Advisor and the child’s Provider must be informed of any changes to this information. I certify that the supplied information is correct, and hereby authorize the Provider to follow the aforementioned instructions or, where necessary, to use discretion in judging the situation or circumstance.Special PermissionsPlease complete all required fields.Emergency Consent *I hereby give permission that in case of an emergency, if I am not immediately available, the physician on duty may hospitalize, secure proper treatment for, and/or order injections, anesthetics, or surgery for my child. I also give permission for my child to be transported to the emergency department of the nearest hospital, with no liability on the driver’s part.I give permission for the following to be applied to my child (select all that apply) *SunscreenMoisturizing Skin LotionLip BalmInsect RepellentHand SanitizerDiaper CreamNone of the AboveParents must supply the product in its original container, and label with the child’s name.Providers must follow instructions on the package for the above products or otherwise provided in writing by parent belowOutdoor Play PermissionI give permission for my child to play outdoors, 2 hours daily, weather depending, in the following locations:Provider's Yard *YesNoRestrictions or requirements on play in the provider's yard:Local Park & Playground *YesNoRestrictions or requirements on play at the local park and playground:Outings within city limits (e.g. playgrounds, libraries, museums) *YesNoRestrictions or requirements on outings within city limits:Pool & Water SafetyI give permission for my child to visit the following locations, supervised by the provider:Public Splash Pads *YesNoPublic Swimming Pools with lifeguards on duty *YesNoPublic Beaches with lifeguards on duty *YesNoPublic Splash Pads *YesNoPublic Swimming Pools with lifeguards on duty *YesNoPublic Beaches with lifeguards on duty *YesNoPlease indicate your child's swimming ability: *Non-swimmerLife jacket requiredIndependent (moderate)Independent (strong)Additional Requirements/Restrictions for Water Play:*Parents are to supply life jackets if requiredPhotographsPlease complete all required fields.I give permission for my child to be filmed or photographed on occasion during the period they are enrolled in the program. *YesNoI give permission for photographs/videos of my child to be used for staff development, provider training, agency orientation, the promotion of Home Child Care in the community, or for display in the Resource Centre. *YesNoAlternate CarePlease complete all required fields.I give permission for my child to have an agency-approved substitute provider for: *Emergencies*AppointmentsPeriods exceeding one day*Permission must be granted for emergency situations.School Transport ArrangementsPlease provide details on school transportation arrangements.I have made arrangements for school aged children to get to and from the provider's home. *YesNoI have made arrangements for school aged children to get to and from the provider's home. *YesNoPlease describe your child's travel arrangements to and from school.The aforementioned permissions may be terminated on written notice by the undersigned. This certifies all provided information is correct to the best of your knowledge.Parent/Guardian Signature *Start signing your signature hereYour browser does not support e-Signature field.Date *Submit RegistrationPlease do not fill in this field.