Application Form

Child's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Child's Address
Street Address City Province Postal Code
Mother's Information
Mother's Name
First Last
Mother's Home Address
Street Address City Province Postal Code
Mother's Home Phone
Mother's Employer
Mother's Work Address
Street Address City Province Postal Code
Mother's Work Phone
Mother's Cell Phone
Mother's Email*
Father's Information
Father's Name
First Last
Father's Address
Street Address City Province Postal Code
Father's Home Phone
Father's Employer
Father's Work Address
Street Address City Province Postal Code
Father's Occupation
Father's Work Phone
Father's Cell Phone
Father's Email
Emergency Contacts Information
Emergency Contact Name*
First Last
Emergency Contact Phone*
Emergency Contact Address*
Street Address City Province Postal Code
Relationship to Child*
Authorized Contacts
These are contacts to whom the child may be released.
Contact #1 Name*
First Last
Contact #1 Phone*
Contact #2 Name
First Last
Contact #2 Phone
Registration Information
Desired Starting Date*
MM slash DD slash YYYY
Care Required*
- Select All
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Start Time*
: Hours
Minutes
AM/PM
End Time*
: Hours
Minutes
AM/PM
About Your Child
Has your child had any previous school experience?
Does your child take a nap?
- Morning
- Afternoon
How many hours does your child sleep at night? (Approximately)
Is your child toilet trained?
- Yes
- No
Does your child use any special word for toileting?
Describe your child’s appetite
- always hungry
- never hungry
- snacks
- snacks all day
- eats at mealtime
- has to be coaxed to eat
Are there any foods your child may not or cannot eat? (due to allergies, religious customs, etc.)
Are there any foods your child dislikes?
Child’s Special Interests
- singing
- painting
- stories
- trucks
- pets
- music
- outside play
- coloring
- other
Is your child generally
- cooperative
- shy
- competitive
- happy
- aggressive
- sensitive
- submissive
- angry
Your child does what is asked of him/her?
- usually
- seldom
Things that comfort your child
Things that scare your child
Cultural habits / home issues that affect the child's behavior
List other behaviors characteristics of your child
Medical Information
Alberta Health Care Number*
Child's Physician*
Physician's Address*
Street Address City Province Postal Code
Physician's Phone Number*
Has the child had
- Polio
- German Measles
- Scarlet Fever
- Rheumatic Fever
- Diptheria
- Chicken Pox
- Mumps
- Measles
- Whooping Cough
Is the child subject to
- Allergies
- Asthma
- Epilepsy Diet
- Diabetes
- Hay Fever
- Restrictions
- Tonsillitis Ear
- Heart Conditions
- Skin Conditions
- Infections
- Reaction to Insect Bites
Please elaborate on above if necessary
Does your child have drug interactions of any kinds? (Please name)
Does your child have any food allergies? (Please name)
Is your child on any medications or treatments on an ongoing basis, and if so, what?
Has your child had any major operations? If so, when?
Immunizations - Whooping cough, Diptheria, Tetanus, Polio (one shot)
- 2 months
- 4 months
- 6 months
- 18 months
- Measles 1 year
- German Measles (girls only) Grade 6
Do you have any other comments?
Admisison Agreement
We ask that all Riverbend Montessori Child Care sign and return this admission agreement. (This agreement also covers other areas not previously mentioned in the handbook- please read carefully).

I have received, read, understood and accepted the policies written within this handbook, and accept the responsibilities of myself as a parent regarding: the payment of fees to be received on or before the fifth day of the month in which my child is registered.

The following of procedures as outlined under the fees policy page with regards to supplying post-dated cheques, notice of termination; no fee reductions for holidays and absences; retention of receipts given and payment of applicable additional fees.

The picking up of my child prior to the 5:45 pm closing time.

Notifying the center when my child will be absent or needs to be picked up by someone other than myself. Providing alternate care for my child on the days he/she is ill; or becomes ill while at school or the center.

Furthermore. As a parent of Riverbend Montessori Child Care, I agree to:

Meet with the Child Care staff should they have concerns regarding my child’s behaviour or conduct.

Allow Riverbend Montessori Child Care staff to obtain medical aid for my child in the event of an emergency, realizing that this may involve the transportation of my child via a staff’s personal vehicle or an ambulance.

Allow my child to be photographed or video taped for the purpose of internal (Centre only) interest.

If you wish to terminate your childcare position, we ask that you provide one month written notice.

I have read, understood the accept the center’s responsibilities and policies in regard to discipline, illness, administration of medication, arrival and dismissing procedures and emergency evacuations.
Notice Regarding Facility / Area Use and Fieldtrips
As a parent of Riverbend Montessori Child Care Centre, I understand that centre uses the following areas and facilities as part of group activities for kids:

- All field areas in and around The Riverbend Shopping Plaza
- Riverbend Library
- Riverbend Senior home
- Riverbend Safeway.
- Any of the local parks Falconer Road Park, Henderson Park.

By signing this form, I give permission for my child to use all the area and facilities as outlined above without any prior notification being given.

I understand that all other outings or fieldtrips will be posted and that I will need to sign for them on an individual basis.
Terms and Conditions
1. The Center agrees to notify the parent(s)/guardian(s) whenever the child becomes ill and the parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so, requested by the center.

2. The parent(s)/guardian(s) authorize the Center to obtain immediate medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately.

3. The parent(s)/guardians agree to inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed a reportable communicable disease, as defined by the Alberta health except for life threatening diseases, which must be reported immediately.

NOTE: Any information regarding child will not be shared without parental consent.
Consent*
- I agree to the terms and conditions
Today's Date
MM slash DD slash YYYY
Your Name
First Last
Your signature
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Application Form

Mother's Information

Father's Information

Emergency Contacts Information

Authorized Contacts

Registration Information

About Your Child

Medical Information

Admisison Agreement

Notice Regarding Facility / Area Use and Fieldtrips

Terms and Conditions

Get in Touch

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