Registration

admin@churchillpark.ca |

403-266-4656

Kids@ Churchill Park - PlayPenn

Child Profile

Family Name

Family Name

First Parent

Relation to Child

First Name

Last Name

Cell Phone

Home Phone

Address

City

Province

Postal Code

Work Name

Work Phone

Work Address

Birthdate

Email Address

By providing your email address you are implying consent to receive occassional email messages from our centre

Alternate Email

Obesidian Employee ID

Second Parent

Relation to Child

First Name

Last Name

Cell Phone

Home Phone

Address

City

Province

Postal Code

Work Name

Work Phone

Work Address

Birthdate

Email Address

By providing your email address you are implying consent to receive occassional email messages from our centre

Alternate Email

Obesidian Employee ID

First Child

Given Name

Last Name

Goes By

Birthdate

Sex

Custody note

Living Arrangements

Child lives with

Mother

Father

Other

Other Guardian

Is there a custody agreement?

No Yes

Custody Agreement Notes

Attending grade 1 to 6

No Yes

School Name

Enrolment

Desired Start Date

Program

Medical

Health Care #

Physician's Name

Physician's Phone

Diet Restrictions

Allergies

Other Medical Concerns

Does your child receive medication on an ongoing basis?

No Yes

Medication Details

Subsidy

Subsidy is approved

Amount Approved

I have applied for subsidy

Application Date

I will apply for subsidy

I need help applying for subsidy

I do not plan to apply for subsidy

Other questions, comments or notes

Second Child

Given Name

Last Name

Goes By

Birthdate

Sex

Custody note

Living Arrangements

Child lives with

Mother

Father

Other

Other Guardian

Is there a custody agreement?

No Yes

Custody Agreement Notes

Attending grade 1 to 6

No Yes

School Name

Enrolment

Desired Start Date

Program

Medical

Health Care #

Physician's Name

Physician's Phone

Diet Restrictions

Allergies

Other Medical Concerns

Does your child receive medication on an ongoing basis?

No Yes

Medication Details

Subsidy

Subsidy is approved

Amount Approved

I have applied for subsidy

Application Date

I will apply for subsidy

I need help applying for subsidy

I do not plan to apply for subsidy

Other questions, comments or notes

Third Child

Given Name

Last Name

Goes By

Birthdate

Sex

Custody note

Living Arrangements

Child lives with

Mother

Father

Other

Other Guardian

Is there a custody agreement?

No Yes

Custody Agreement Notes

Attending grade 1 to 6

No Yes

School Name

Enrolment

Desired Start Date

Program

Medical

Health Care #

Physician's Name

Physician's Phone

Diet Restrictions

Allergies

Other Medical Concerns

Does your child receive medication on an ongoing basis?

No Yes

Medication Details

Subsidy

Subsidy is approved

Amount Approved

I have applied for subsidy

Application Date

I will apply for subsidy

I need help applying for subsidy

I do not plan to apply for subsidy

Other questions, comments or notes

Emergency Contacts (Other than parents)

Relation to Child

First Name

Last Name

Cell Phone

Home Phone

Address

City

Province

Postal Code

Authorized for Pickup

Relation to Child

First Name

Last Name

Cell Phone

Home Phone

Address

City

Province

Postal Code

Authorized for Pickup

Wrap up

How did you first hear about us?

Print Directory

Drive by (saw the signs)

Word of Mouth (referral)

Web Search

Alberta Government Website

Print Directory

Other

Drive by (saw the signs)

Word of Mouth (referral)

Web Search

Alberta Government Website

Other

Powered by TimeSavr