Daycare Registration FormDaycare for Your Child in Preschool, Toddlers, Infants Details Parent Signature Please enable JavaScript in your browser to complete this form.Hours of Care - Step 1 of 8Choose any time between 7am and 6pmMondayFirstLastTuesdayFirstLastWednesdayFirstLastThursdayFirstLastFridayFirstLastNextName *FirstLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM/DD/YYYYHome Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeLanguage(s) Spoken at HomePreviousNextName *FirstLastRelationship to Child *Primary Phone Number *Alternate Phone NumberEmail *Address same as child? *YesNoAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCustody Arrangements (if applicable)Are there custody arrangements pertaining to legal right of access to your child?YesNoIf YES, please provide a copy of the appropriate legal documentation (e.g., court order). * Click or drag a file to this area to upload. Name (s) of custodial parent(s): *FirstLastName (s) of individuals prohibited from accessing/picking up your child: FirstLastPreviousNextIn the event of an emergency, if a parent cannot be reached, the following individual(s) may be contacted.Name *FirstLastRelationship to Child *Phone *Alternate PhoneAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAuthorized to pick-up child? *YesNoAdd another Emergency ContactYesName *FirstLastRelationship to Child *Phone *Alternate PhoneAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAuthorized to pick-up child? *YesNoAdditional Emergency InformationPreviousNextHealth InformationHealth Canada Infectious Diseases: https://www.canada.ca/en/public-health/services/infectious-diseases.htmlDoes your child have a medical need that requires additional support (e.g. Diabetes)? *YesNoIf yes, an individualized plan for children with medical needs must be developed between the parent and the home childcare agency prior to the child’s first day of care.Immunization Records Click or drag a file to this area to upload. Please provide a copy of your child’s immunization record (e.g., yellow card) to the agency prior to your child’s first day of care. If you do not have an immunization record, please fill in the chart below.If you have chosen not to immunize your child, a Statement of Medical Exemption form or a Statement of Conscious or Religious Belief form must be completed and provided to the agency. These forms are available on the Ministry of Education’s website.Ontario’s Publicly Funded Immunization Schedule - http://www.health.gov.on.ca/en/pro/programs/immunization/schedule.asAllergy InformationDoes your child have a life-threatening allergy (e.g., anaphylactic to peanuts or bee stings)? *YesNoIf yes, an individualized plan for an anaphylactic allergy that includes emergency procedures must be developed between the parent and the home childcare agency prior to the child’s start date.Does your child have any allergies that are not life-threatening (food or other substance (e.g., latex))? *YesNoIf yes, please provide relevant details, including what your child is allergic to, symptoms of a reaction and treatment. *PreviousNextSleep ArrangementsHow many naps does your child have each day?At what times does your child nap?How long does your child usually nap?Does your child have any special sleep arrangements (e.g., specific comfort item, soother)? *YesNoIf yes, please provide relevant below. *Physical RequirementsIs your child in diapers? *YesNoIf no, my child:Uses the washroom independentlyRequires assistanceRequires full supportPlease provide details, if necessary.Does your child require any additional support with respect to physical activity? *YesNoIf yes, please provide relevant details. *Please indicate any additional information which is relevant to the care of your child (e.g., prone to colds, frequent shoulder dislocation, etc.)PreviousNextParent Name *FirstLastSignature of Parent *By typing your full name above you agree to the terms and conditions.Date Signed *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM/DD/YYYYNote: ‘Parent’ is defined as a person having lawful custody of a child or person who has demonstrated a settled intention to treat a child as a child of his or her family, and includes legal guardians.PreviousNextAuthorization for Non-Prescription Skin ProductsAuthorization for Non-Prescription Skin ProductsChild’s Full Legal NameFirstLastDate of BirthThe following non-prescriptionitems may be applied to my child in accordance with the manufacturer’s instructions on the original container (please check off)SunscreenDiaper Creams/OintmentLip balmHand sanitizersInsect repellentLotionsJust For Kids has agreed to provide:Note: Consider adding the brand name of the non-prescription items for transparency.Parent has agreed to provide:Note: Consider adding the brand name of the non-prescription items for transparency.Signature of Parent *By typing your full name above you agree to the terms and conditions.DateMM/DD/YYYYPreviousSubmit