Application form for Riverbend Montessori Child's Name* First Last Date of Birth* MM slash DD slash YYYY Child's Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Mother's InformationMother's Name First Last Mother's Home Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Mother's Home PhoneMother's EmployerMother's Work Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Mother's Work PhoneMother's Cell PhoneMother's Email* Father's InformationFather's Name First Last Father's Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Father's Home PhoneFather's EmployerFather's Work Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Father's OccupationFather's Work PhoneFather's Cell PhoneFather's Email Emergency Contacts InformationEmergency Contact Name* First Last Emergency Contact Phone*Emergency Contact Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Relationship to Child*Authorized ContactsThese are contacts to whom the child may be released.Contact #1 Name* First Last Contact #1 Phone*Contact #2 Name First Last Contact #2 PhoneRegistration InformationDesired Starting Date* MM slash DD slash YYYY Care Required* Select All Monday Tuesday Wednesday Thursday Friday Start Time* : Hours Minutes AM PM AM/PM End Time* : Hours Minutes AM PM AM/PM About Your ChildHas 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 childThings that scare your childCultural habits / home issues that affect the child's behaviorList other behaviors characteristics of your childMedical InformationAlberta Health Care Number*Child's Physician*Physician's Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon 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 necessaryDoes 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 AgreementWe 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 FieldtripsAs 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 Conditions1. 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 signatureCAPTCHA
