Enrollment Application

Child Information

First Name *

Last Name *

Date of Birth *

Gender *

Home Address *

Preferred Start Date *

Program *

Parent/Guardian Information

First Name *

Last Name *

Relationship to Child *

Phone Number *

Email Address *

Occupation *

Workplace Address *

Emergency Contact (Other than parents/guardians)

Full Name *

Relationship to Child *

Phone Number *

Workplace Phone Number

Medical Information

Pediatrician Name *

Phone Number *

Clinic/Hospital *

Current Medication Taken (if any)

Medical Conditions/Special Needs

Any allergies or restrictions? *

Yes

Schedule and Pick-up Authorization

Days Attending

Drop-Off Time

Pick-up Time

Persons Authorized to Pick-up Child (other than parents)

Name

Phone

Relationship

Additional Information

What concerns your child when upset?

Any special interests or favorite activities?

Anything else we should know to support your child?

Authorization & Agreement

Give permission for my child to be photographed for daycare activities and educational materials

Give permission for my child to participate in supervised field trips

Authorize Arize and Shine Early Learning Centre to seek emergency medical care for my child if I cannot be reached

Have read and agree to the centre's policies and procedures *

Guardian/Parent Signature *

By typing your name above, you are providing your digital signature and agreeing to all terms and conditions.

Enrollment Application

Application Form