Registration

info@cpccs.org | 7804293033

Canada Place Child Care Society

Online Waitlist Registration

Family

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

Email Address

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

Keycard

Second Parent

Relation to Child

First Name

Last Name

Cell Phone

Home Phone

Address

City

Province

Postal Code

Work Name

Work Phone

Work Address

Email Address

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

Notes

Keycard

First Child

Given Name

Last Name

Goes By

Birthdate

Sex

Area Permission Form

Approved

Not Approved

FED

Living Arrangements

Child lives with

Mother

Father

Other

Other Guardian

Is there a custody agreement?

No Yes

Custody Agreement Notes

Enrolment

Desired Start Date

Program

Frequency

Medical

Health Care #

Physician's Name

Physician's Phone

Diet Restrictions

Allergies

Other Medical Concerns

Is your child's immunization up to date?

No Yes

Does your child receive medication on an ongoing basis?

No Yes

Medication Details

Please tell us any additional information about your child we should be aware of.

Second Child

Given Name

Last Name

Goes By

Birthdate

Sex

Area Permission Form

Approved

Not Approved

FED

Living Arrangements

Child lives with

Mother

Father

Other

Other Guardian

Is there a custody agreement?

No Yes

Custody Agreement Notes

Enrolment

Desired Start Date

Program

Frequency

Medical

Health Care #

Physician's Name

Physician's Phone

Diet Restrictions

Allergies

Other Medical Concerns

Is your child's immunization up to date?

No Yes

Does your child receive medication on an ongoing basis?

No Yes

Medication Details

Please tell us any additional information about your child we should be aware of.

Third Child

Given Name

Last Name

Goes By

Birthdate

Sex

Area Permission Form

Approved

Not Approved

FED

Living Arrangements

Child lives with

Mother

Father

Other

Other Guardian

Is there a custody agreement?

No Yes

Custody Agreement Notes

Enrolment

Desired Start Date

Program

Frequency

Medical

Health Care #

Physician's Name

Physician's Phone

Diet Restrictions

Allergies

Other Medical Concerns

Is your child's immunization up to date?

No Yes

Does your child receive medication on an ongoing basis?

No Yes

Medication Details

Please tell us any additional information about your child we should be aware of.

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

Alberta Government Website

Web Search

Word of Mouth (referral)

Other

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