Shawkwunlee Daycare Registration

Kwänlin

17°C

Däkwäkäda

16°C

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9°C

Phone

Child Information:

Name

First Middle Last

Address

Street Address Address Line 2 City Province Postal Code

Home Phone:

Date of Birth:

Gender:

Male

Female

Start Date:

CAFN Citizen

Yes

CAFN Staff member

Yes

Parent-Guardian 1 Information Name:

Name

First Last

Address

Street Address Address Line 2 City Province Postal Code

Home Phone:

Relation to Child:

Employer:

Work Phone:

Ext

Cell Phone:

Parent-Guardian 2 Information Name:

Name

First Last

Address

Street Address Address Line 2 City Province Postal Code

Home Phone:

Relation to Child:

Employer:

Work Phone:

Ext

Cell Phone:

Authorized Pick Up List Person must be 19 years of age or older and I authorize the following people: (In addition to the Parent/Guardian 1 & 2 information) already listed on page 1) to pick up my child and/or be contacted in case of emergency

Contact #1

Name

First Last

Phone

Relationship

Address

Street Address Address Line 2 City Province Postal Code

Contact #2

Name

First Last

Phone

Relationship

Address

Street Address Address Line 2 City Province Postal Code

Contact #3

Name

First Last

Phone

Relationship

Address

Street Address Address Line 2 City Province Postal Code

The Following People are NOT Authorised to pick up my child

Name

Phone

Name

Phone

Please note that we will ONLY release a child to the people LISTED on this form/emergency permission card. A child will only be released to people not listed, when a staff has received WRITTEN OR VERBAL CONSENT FROM THE PARENT/GUARDIAN confirming that the person is permitted to take the child PRIOR to pick up.

HEALTH INFORMATION:

Family Doctor name

First Last

Family Doctor phone

Health card number:

Are your child’s immunisations up to date?

Yes

Does your child have any allergies?

Yes

Please list what is your child allergic to:

Is this allergy life threatening?

Yes

What is the reaction of the allergy?

Specific Instructions about the allergy and the reactions:

If an allergy exists you must request the required consent forms for any medication your child may need (ex. EpiPen, Benadryl)

Does your child have any health or medical issues such as Special medications, Vision Hearing, Speech/Language, Require a special diet or Other?

Yes

Please specify and give us specific instructions

For medication to be administered at the centre, you must request the required medication consent forms

Social and Behavior information

When filling out this section we encourage parents to give us as much information as possible. Knowing about your child’s social and behaviour requirements before hand allows us to take a proactive approach to their individual needs and therefore help to ensure that they are successful and enjoy the program.

Display signs of anxiety in a group of children?

Yes

Please explain:

Require assistance dressing?

Yes

Require assistance toileting?

Yes

Require assistance feeding?

Yes

Behaviour Issues?

Yes

Please explain how you handle the behaviour issues at home so we can work together on it:

Does your child have any fears?

Yes

Please explain

Does your child have any difficulties sleeping/or a special routine?

Yes

Please explain

Field Trips

Parent/Guardian (please print):

Parent/Guardian’s Signature:

Date

Photos and Videos

I give permission for Photographs and videos of my child to be used in publicity in which the program participates ( ie.. Newsletters for daycare and CAFN as well as the web pages for daycare and CAFN)

Yes

Parent/Guardian (please print):

Parent/Guardian’s Signature:

Date

Medical Consent

It is the Child Care’s policy to notify a parent when a child is ill or in need of medical attention. Occasionally we are unable to contact parents and we need to get immediate help for the child. Our procedure is to have the child taken to the nearest emergency service by ambulance If an ambulance is not available, the caregiver/staff of the childcare will transport the child.

Parent/Guardian (please print):

Parent/Guardian’s Signature:

Date

Policy Agreement between Shawkwunlee Daycare & Parent/Guardian

Signature (Parent/Guardian)

Date

Signature (Daycare Manager) Danielle Evans

Date

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Whitehorse Office

304 Jarvis Street

Whitehorse, YT Y1A 2H2

(867) 456-6888

Haines Junction Office

#1 Allen Place, P.O. Box 5310

Haines Junction, YT Y0B 1L0

(867) 634-4200

Community Buildings

Takhini Hall 667-6701

Da Ku Store 634-3307

Youth Center 634-2012

Mun Kų 634-7001

Champagne Hall 634-2336

Klukshu Hall 634-2342

[email protected]

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