Registration

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

Alternate Email

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

Alternate Email

First Child

Given Name

Last Name

Goes By

Birthdate

Sex

Living Arrangements

Child lives with

Mother

Father

Other

Other Guardian

Is there a custody agreement?

No Yes

Custody Agreement Notes

Enrolment

Desired Start Date

1st Priority

Not Applicable

Canadian Union of Postal Workers (CUPW)

Kids@ Churchill Park corporate partners (ENMAX, Pennwest/Obsidian/Syncrude, Suncor, The Kahanoff Centre)

Kids@ Churchill Park Staff

2nd Priority

Not Applicable

Previous Kids@ Churchill Park Family

Sibling of current Kids@ Churchill Park child/children

Medical

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

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