Pre-Registration Form

Apply for *:

Program Information (2 yrs to 5 yrs)

Program Days *:

Extended Care Needed *:

Care Days and Hours, Please specify days and hours: *:

Child’s Information

Child's First Name *:

Child's Middle Name:

Child's Last Name *:

Gender *:

Date of Birth *:

Home Telephone Number *:

Street *:

City *:

Zip/Postal Code *:

State *:

Country *:

Language Spoken *:

Please list the names and ages of siblings

Family Information

Mother's First Name *:

Father's First Name *:

Mother's Last Name *:

Father's Last Name *:

Mother's Employer:

Father's Employer:

Mother's Address:

Father's Address:

Mother's Work Phone:

Father's Work Phone:

Mother's Cell Phone *:

Father's Cell Phone *:

Mother Email *:

Father Email *:

Child Lives With *:

Pick Up Information

Pick Up Person #1 *:

Pick Up Person #1 Home Phone *:

Pick Up Person #1 Cell Phone:

Pick Up Person #1 Relationship to Child:

Pick Up Person #2:

Pick Up Person #2 Home Phone:

Pick Up Person #2 Cell Phone:

Pick Up Person #2 Relationship to Child:

Pick Up Person #3:

Pick Up Person #3 Home Phone:

Pick Up Person #3 Cell Phone:

Pick Up Person #3 Relationship to Child:

Child's Profile

Do you wish your child to have a nap?:

For how long? (if applicable):

Has your child had any previous school, playgroup or nursery experience? If so, where and how often?

List any organized activities that your child has participated in (e.g. swimming lessons, library groups, etc.)

What are your child’s interests?

Does your child have fears or aversions?

Eating Patterns: Please comment on your child’s eating habits and food preferences:

Sleeping Pattern: Please comment on your child’s sleeping pattern:

Is your child toilet-trained?:

Can your child manage their washroom routine independent of an adult?

Can your child verbally communicate his/her needs effectively?

If applicable, please write the name of your child’s nanny or other primary caregiver

Has your child ever been hospitalized?:

If Yes, For What?:

How much screen time does your child have each day?

How much screen time does your child have each week?

What type of screen time? (TV/iPad/computer, etc.)

What shows/games does your child watch/play?

Additional Information

Other information you wish us to know: