Under the Day Nurseries Act, the following information is required to be on file in the centre prior to your child attending.
Enrollment depends on every detail of this form being completed in advance of attendance.
ENROLLMENT FORM - PAGE 1 OF 3
Discovery Child Care of Peterborough, 844 Park Street South, Peterborough, ON, K9J 3T8, (705) 743-0965
Date of Enrollment: _____/_____/_____ End Date: _____/_____/_____
   (dd)   (mm)   (yy)    (dd)   (mm)   (yy)
Schedule: Mon. _____-_____ Tues._____-_____ Wed. _____-_____ Thurs. _____-_____ Fri. _____-_____

Or sporadic with prior approval?    (if yes, please check)

Child's Name: _______________________________________________________     Sex: F / M
                                                  (last)                             (first)                             (middle)                                (circle one)

Address: _____________________________________________________________________
                                       (street #, name)              (city)              (province)              (postal code)

Telephone: ___________________________    Date of Birth: ______ / ______ / ______   (dd/mm/yy)

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Mother's Name: _______________________________________________________
                                                  (last)                             (first)                             (middle)

Address (if different than child's): ____________________________________________________
                                                                         (street #, name)              (city)              (province)              (postal code)

Home Phone: (_____)________________   Cell Phone: (_____)___________________

Mother's Work or School Name: __________________________________________________

Address: _____________________________________________________________________
                                       (street #, name)              (city)              (province)              (postal code)

Work or School Phone: (_____)___________________________

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Father's Name: _______________________________________________________
                                                  (last)                             (first)                             (middle)

Address (if different than child's): ____________________________________________________
                                                                         (street #, name)              (city)              (province)              (postal code)

Home Phone: (_____)________________   Cell Phone: (_____)___________________

Father's Work or School Name: __________________________________________________

Address: _____________________________________________________________________
                                       (street #, name)              (city)              (province)              (postal code)

Work or School Phone: (_____)___________________________


ENROLLMENT FORM - PAGE 2 OF 3
Discovery Child Care of Peterborough, 844 Park Street South, Peterborough, ON, K9J 3T8, (705) 743-0965

Child's Name: _______________________________________________________

MANDATORY LOCAL EMERGENCY CONTACT PERSON (OTHER THAN PARENTS):

Name: _______________________________________________________
                                  (last)                             (first)                             (middle)

Address: _____________________________________________________________________
                                       (street #, name)              (city)              (province)              (postal code)

Home Phone: (_____)________________   Cell Phone: (_____)___________________

Work or School Name: ________________________________________________________

Address: _____________________________________________________________________
                                       (street #, name)              (city)              (province)              (postal code)

Work or School Phone: (_____)___________________________

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Other(s) to whom the child may be released:

Name: _______________________________________________________
                                  (last)                             (first)                             (middle)

Address: _____________________________________________________________________
                                       (street #, name)              (city)              (province)              (postal code)

Home Phone: (_____)________________   Cell Phone: (_____)___________________

Work or School Name: ________________________________________________________

Address: _____________________________________________________________________
                                       (street #, name)              (city)              (province)              (postal code)

Work or School Phone: (_____)___________________________

Name: _______________________________________________________
                                  (last)                             (first)                             (middle)

Address: _____________________________________________________________________
                                       (street #, name)              (city)              (province)              (postal code)

Home Phone: (_____)________________   Cell Phone: (_____)___________________

Work or School Name: ________________________________________________________

Address: _____________________________________________________________________
                                       (street #, name)              (city)              (province)              (postal code)

Work or School Phone: (_____)___________________________


ENROLLMENT FORM - PAGE 3 OF 3
Discovery Child Care of Peterborough, 844 Park Street South, Peterborough, ON, K9J 3T8, (705) 743-0965

Child's Name: _______________________________________________________

MEDICAL INFORMATION:

Child's Health Card Number (optional): ________________________________

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Physician's Name: _____________________________________________________________________

Address: _____________________________________________________________________
                                       (street #, name)              (city)              (province)              (postal code)

Phone: (_____)___________________________

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Please indicate which, if any, of the following communicable diseases your child has had:
(if yes, please check)

Measles   Chicken pox   Whooping Cough   Intestinal Diseases   Meningitis

Other, please specify: ________________________________________________________________

____________________________________________________________________________________

Does your child have any conditions requiring medical attention of which the staff should be aware? E.g. epilepsy, diabetes, allergies, special requirements for diet, rest, exercise, etc. Please attach written instructions if necessary.

PLEASE NOTE: ANAPHYLAXIS REQUIRES ADDITIONAL FORMS TO BE COMPLETED

____________________________________________________________________________________

____________________________________________________________________________________

IMMUNIZATION:   Since it is a parent's right to choose immunization for a child, please indicate which, if any, your child has received. If, for reasons of conscience or religion, your child is not immunized, please provide a written statement to that end.

Primary series (baby needles, DPTP - Diphtheria, Whooping Cough, Tetanus, Polio) Dates
     
Booster - DPTP      
Measles, Mumps, Rubella Trivirix (MMR)      
Optional - Haemophilis Influenza      
Optional - Tuberculin test results      

Please provide any further information concerning your child/family that the staff should be aware of (attach additional page if necessary). ___________________________________________________________________________

Attachments: (Y/N) ______  # ______

Parent(s) Signature: _____________________   _____________________  Date: ___/___/___ (dd)(mm)(yy)