admin@churchillpark.ca      403-266-4656
Kids@ Churchill Park - PlayPenn
Intake Form

Family

Family Name

Family Name
 

Mother (or Guardian)

Relation to Child
First Name Last Name
Home Phone Cell Phone
Address
City
Work Work Phone
Work Address
School School Phone
School Address
Birth Date
Email Address

Father (or Guardian)

Relation to Child
First Name Last Name
Home Phone Cell Phone
Address
City
Work Work Phone
Work Address
School School Phone
School Address
Birth Date
Email Address

Emergency Contacts

This space is intended for emergency contacts other than the parents
First Name Last Name
Address
City
Home Phone Cell Phone
Relation to Child
Authorized for Pickup
 
First Name Last Name
Address
City
Home Phone Cell Phone
Relation to Child
Authorized for Pickup

First Child

Personal

First Name Last Name
Nick Name
Birth Date Sex
Child Lives With     
Attending grade 1 to 6?   School Name
Is there a custody agreement?
 
Other questions, comments or notes
 

Enrolment

Program
Desired Start Date 
 

Medical

Health Care #
Physician's Name Physician's Phone
Medical Concerns
Diet Restrictions
Allergies
Is the child's immunization up to date?    
Does your child receive medication on an ongoing basis?    
If yes, please specify
 

Subsidy

Amount
Application Date
 
 
 

Second Child

Personal

First Name Last Name
Nick Name
Birth Date Sex
Child Lives With     
Attending grade 1 to 6?   School Name
Is there a custody agreement?
 
Other questions, comments or notes
 

Enrolment

Program
Desired Start Date 
 

Medical

Health Care #
Physician's Name Physician's Phone
Medical Concerns
Diet Restrictions
Allergies
Is the child's immunization up to date?    
Does your child receive medication on an ongoing basis?    
If yes, please specify
 

Subsidy

Amount
Application Date
 
 
 

Third Child

Personal

First Name Last Name
Nick Name
Birth Date Sex
Child Lives With     
Attending grade 1 to 6?   School Name
Is there a custody agreement?
 
Other questions, comments or notes
 

Enrolment

Program
Desired Start Date 
 

Medical

Health Care #
Physician's Name Physician's Phone
Medical Concerns
Diet Restrictions
Allergies
Is the child's immunization up to date?    
Does your child receive medication on an ongoing basis?    
If yes, please specify
 

Subsidy

Amount
Application Date
 
 
 

Wrap Up

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