Sunshine Discoveries
Preschool
REGISTRATION FORM
ABOUT YOUR CHILD
Name of child:
(Last)
(First)
(Middle)
Nickname:
Gender:
Date of birth:
d/m/y
Mailing Address:
Postal Code:
Residence Address:
Home Phone number:
Please attach a copy of your child’s immunization record to this form. If your child
has not been immunized, please sign the statement included with the consent forms.
CLASS SESSIONS
Session Choices: AM session or PM session
Day Choices: Monday & Wednesday or Tuesday & Thursday
1st Choice:
2nd Choice:
3rd Choice:
ABOUT THE FAMILY
Father
Name:
Mother
Name:
Cell Phone Number
Cell Phone Number
Occupation:
Occupation:
Place of work:
Place of work:
Work Phone Number: ___________________
Work Phone Number:
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Sibling(s):
Name:
Age:
Name:
Age:
Name:
Age:
Other adults at home or pets:
The teacher will not release your child to an unauthorized person unless you provide us with written permission
prior to the event. Therefore, please provide the center with at least two contacts, persons who are authorized to
drop off and pick up your child. If these people are not known by the teacher, photo ID will be required at the
time of pick-up.
Authorized Contact:
NAME
RELATIONSHIP
HOME PHONE #
WORK PHONE #
*In the event that a person should not have contact with your child, please inform the teacher, in writing, of that
situation.
PERSONAL PROFILE
1. Has your child previously attended daycare or preschool?
Name of facility:
Dates of attendance:
Concerns (if any):
2. Fears or nervous habits:
3. Is your child comfortable leaving you?
4. What are your child’s favorite activities?
5. What are your child’s least favorite activities?
6. Describe your child’s personality:
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7. What do you expect your child to gain from this preschool experience?
8. Special medication:
Allergies
Please explain:
9. Developmental Concerns or Challenges:
Physical:
Emotional:
Social:
Language:
Any other areas:
10. Indicate any accidents and illnesses your child has had (please give dates):
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IMMUNIZATIONS DECLINED
Please sign the following statement in the event that your child is not immunized.
I,
, declare that my child,
is not immunized. I understand that should there be a suspected or confirmed outbreak of any
of the diseases that a preschooler can be immunized against, I have to remove my child from
preschool until it is cleared by medical professionals.
Signature:
Date:
Parent/Guardian
PHOTO CONSENT
, hereby (☐give OR ☐do not give) NVCSS
I,
permission to have pictures and/or videos taken of my child,
, in the program setting for
general record keeping, art projects, and preschool memories.
Signature: _________________________________
Date: _____________________
CONSENT FORM FOR THE TAKING OF/USE OF PICTURES/VIDEOS
I, ________________________________
(☐give OR ☐do not give) my consent to NVCSS,
through Sunshine Discoveries Preschool, to use pictures/videos of myself and/or my child for
the purpose of circulation within our community. I understand that any pictures/videos made of
myself and/or my child may be used on the public website www.nvcss.ca, and may be use in the
proposed newsletter in the future.
I understand that I may revoke this consent at any time.
Signature: _____________________________
Date: __________________________
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OBSERVATION CONSENT
On occasion the preschool receives a request from other professionals/students from the
community to observe the program. We attempt to do this with the least disturbance to the
children’s routine. I, ______________________(☐give OR ☐do not give) permission for my
child, ______________________, to be observed within the preschool program.
Signature:
Date: _____________
We have read, and agree to comply with the Vision Statement and policies of Nechako Valley
Community Services Society Preschool.
Mother / Guardian Signature:
Print:
Date:
Father / Guardian Signature:
Print:
Date:
For Office Use
Date of Orientation:
Date of Enrollment:
Date of Withdrawal:
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Emergency Contact and Consent – Please Print Clearly
Child’s Name
Birth date
Address
Home phone
Mother’s/Guardian’s Name
Cell Phone
Work Phone
Father’s/Guardian’s Name
Cell Phone
Work Phone
Other Emergency Contact
Phone Number
Relation to Child
Work Phone
Cell Phone
Care Card Number
Physician’s Name
Phone
Dentist’s Name
Phone
Date of last Tetanus shot
Any Allergies or medications? Please explain.
Medical Attention Consent
It is the policy of this centre to notify a parent when a child is ill or needs medical attention. Occasionally we
cannot contact parents and we need to get immediate help for the child. Our procedure is to take the child to the
nearest emergency centre.
Please sign the consent below so that we can take appropriate action on behalf of your child. We will take this
consent with us to the emergency centre.
I hereby give consent for my child,
the Staff of NVCSS Pre-school when I cannot be contacted.
, to be taken to the nearest emergency centre by
I hereby give consent for my child,
, to receive medical treatment.
Date
Signature of Parent/Guardian
Witness
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Pre-authorized Debit Agreement
Sunshine Discoveries Preschool
Nechako Valley Community Services Society
Please complete the Pre-Authorized Debit (PAD) Plan agreement below
I/we authorize Nechako Valley Community Services Society and the financial institution designated
(or any other financial institution I/we may authorize at any time) to begin deductions as per my/our
instructions for monthly regular recurring payments and/or one-time payments from time to time, for
payment of all charges arising under my/our Nechako Valley Community Services Society account.
Regular monthly payments for $125.00 will be debited to my account on the 1st day of each month.
Nechako Valley Community Services Society will provide written notice in September of the current
year of the debit schedule. Nechako Valley Community Services Society will obtain my/our
authorization for any other one-time or sporadic debits.
This authority is to remain in effect until Nechako Valley Community Services Society has received
written notification from me/us of its change or termination. This notification must be received at
least ten (10) business days before the next debit is scheduled at the address provided below. I/we
may obtain a sample cancellation form, or more information on my/our right to cancel a PAD
agreement at my/our financial institution or by visiting www.cdnpay.ca
Nechako Valley Community Services Society may not assign this authorization, whether directly or
indirectly, by operation of law, change of control or otherwise, without providing at least ten (10)
days prior written notice to me/us.
I/we have certain recourse rights if any debit does not comply with this agreement. For example, I/we
have the right to receive reimbursement for any PAD that is not authorized or is not consistent with
this PAD agreement. To obtain a form for a Reimbursement Claim, or for more information on
my/our recourse rights, I/we may contact my/our financial institution or visit www.cdnpay.ca
Date:
PLEASE PRINT
Name(s):
NVCSS
Address:
Type
City/Town:
Financial
Province:
Postal Code:
Phone #: (Res.)
of
Account
Service:
Personal:
Institution
_
#:
Business:
(FI):
FI Account #:
FI Transit #:
Branch—5 digits
(Bus.)
FI—3 digits
Address:
City/Town:
Province:
Postal Code:
Authorized Signature(s):
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