403 632 6539

Pincher Creek Community Early Learning Centre

Online Registration

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
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
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

Birth Date

Sex

Child Lives With

Mother Father Other

Attending grade 1 to 6?

No Yes

School Name

Is there a custody agreement?

Enrolment

Program

Desired Start Date

Full Time

Part Time

Drop In

I have signed Consent for the Provider and/or Program Staff to seek Emergency Medical Treatment if necessary

Medical

Health Care #

Physician's Name

Physician's Phone

Medical Concerns

Diet Restrictions

Allergies

Is the child's immunization up to date?

Yes No

Does your child receive medication on an ongoing basis?

Yes No

If yes, please specify

Subsidy

Subsidy is approved

Amount

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

Second Child

Personal

First Name

Last Name

Birth Date

Sex

Child Lives With

Mother Father Other

Attending grade 1 to 6?

No Yes

School Name

Is there a custody agreement?

Enrolment

Program

Desired Start Date

Full Time

Part Time

Drop In

I have signed Consent for the Provider and/or Program Staff to seek Emergency Medical Treatment if necessary

Medical

Health Care #

Physician's Name

Physician's Phone

Medical Concerns

Diet Restrictions

Allergies

Is the child's immunization up to date?

Yes No

Does your child receive medication on an ongoing basis?

Yes No

If yes, please specify

Subsidy

Subsidy is approved

Amount

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

Third Child

Personal

First Name

Last Name

Birth Date

Sex

Child Lives With

Mother Father Other

Attending grade 1 to 6?

No Yes

School Name

Is there a custody agreement?

Enrolment

Program

Desired Start Date

Full Time

Part Time

Drop In

I have signed Consent for the Provider and/or Program Staff to seek Emergency Medical Treatment if necessary

Medical

Health Care #

Physician's Name

Physician's Phone

Medical Concerns

Diet Restrictions

Allergies

Is the child's immunization up to date?

Yes No

Does your child receive medication on an ongoing basis?

Yes No

If yes, please specify

Subsidy

Subsidy is approved

Amount

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

Wrap Up

How did you first hear about us?

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Family

Family Name

Mother (or Guardian)

Father (or Guardian)

Emergency Contacts

First Child

Personal

Enrolment

Medical

Subsidy

Second Child

Personal

Enrolment

Medical

Subsidy

Third Child

Personal

Enrolment

Medical

Subsidy

Wrap Up

How did you first hear about us?

Prove that you're human. Type the following word.

Finish