Ultimate School-Agers Enrolment Form

Last Name______________________________________________________________

First and Middle Name ____________________________________________________

Preferred Name ___________________________Sex____________________________

Address ____________________________________ Postal Code__________________

Phone Number ________________________Unlisted____________________________

Birthdate ___________________D.O.B. Verification ____________________________

Health Card Number (Optional)_____________________________________________

Family Physician’s Name _______________________ Phone Number ______________

Physician’s Address ______________________________________________________

What school does your child attend? __________________________________________

What grade is your child in? ________________________________________________

Who is your child’s teacher? ________________________________________________

List the days and hours your child is in school. _________________________________

Does your child have any food allergies? ______________________________________

If yes, please state what he/she is allergic to ____________________________________

Does your child have any environmental allergies? ______________________________

If yes, please state what she/he is allergic to ____________________________________

Does your child have any drug allergies? ______________________________________

If yes, please state what she/he is allergic to ____________________________________

Does your child’s allergy require any special medical treatment? ___________________

If yes, please explain ______________________________________________________

Does your child react to their allergy through ingestion, inhalation or contact? _________

________________________________________________________________________

What precautions are taken at home to accommodate your child’s allergy? ____________

________________________________________________________________________

Is your child at risk of an anaphylactic reaction due to their allergy? _________________

*IF THE ANSWER IS YES YOU NEED TO FILL OUT A SEPARATE FORM.

Does your child have any dietary restrictions? __________________________________

_______________________________________________________________________

Does your child have any other health concerns Ultimate School-Agers should be aware of? ____________________________________________________________________

________________________________________________________________________

Does your child have any medical conditions Ultimate School-Agers should be aware of?

______________________________________________________________________________________________________________________________________________ Every child is unique including the way they respond to sickness. Are there any signs your child exhibits that are good indicators of being unwell? _______________________

Please list the signs _______________________________________________________

What kind of activities does your child like to do? _______________________________

_______________________________________________________________________

What kind of activities does your child not like to do? ____________________________

________________________________________________________________________

Is there anything else you would like us to know about your child? __________________

________________________________________________________________________

Emergency Contact Information:

Parent/Guardian 1 ________________________________________________________

Home Phone Number ________________ Work Phone Number ___________________

Cell Phone Number _______________________________________________________

Home Address ___________________________________________________________

Workplace Name and Address ______________________________________________

Priority Contact Number 1 2 3 or 4

Parent/Guardian 2 ________________________________________________________

Home Phone Number _________________ Work Phone Number __________________

Cell Phone Number ______________________________________________________

Home Address ___________________________________________________________

Workplace Name and Address ______________________________________________

Priority Contact Number 1 2 3 or 4

Other Emergency Contact: Name ____________________________________________

Home Phone Number ______________________Work Phone Number ______________

Cell Phone Number _______________________ Relationship to Child ______________

Home Address ___________________________________________________________

Workplace Name and Address ______________________________________________

Priority Contact Number 1 2 3 or 4

Other Emergency Contact: Name ____________________________________________

Home Phone Number ______________________Work Phone Number ______________

Cell Phone Number ________________________ Relationship to Child _____________

Home Address ___________________________________________________________

Workplace Name and Address ______________________________________________

Priority Contact Number 1 2 3 or 4

Is there a custody order regarding your child? ________________________________

Is there someone who does not have permission to pick your child up under any circumstances? ________________________________________________________

Are there any custody orders for your child? _______________________________

If yes, please explain _________________________________________________

__________________________________________________________________

Does Ultimate School-Agers have your permission to take pictures of your child? ___________________________________________________________________

State the names of the people who Ultimate School-Agers can release your child to. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please see Appendix A regarding any special instructions for diet and/or exercise.

Does your child have any history of any communicable diseases?

If yes, please state the disease(s) _____________________________________________

________________________________________________________________________

Ultimate School-Agers is prepared for any kind of emergency. Should U.S. encounter an emergency that would require an evacuation we have a specific evacuation center. We have permission to take the children to Courtice Community Complex. Should this happen for any reason you will be informed of our whereabouts after we have safely made it to the Courtice Community Complex. All of the staff are familiar with the Emergency Evacuation Procedures.

Would you be interested in receiving communication through e-mail for our monthly newsletters and upcoming events? ____________________________________________

If so, please state your e-mail address _________________________________________

Your e-mail will be blocked from others and you will only receive information regarding your child’s program.

Comments ______________________________________________________________

________________________________________________________________________

Date of Admission: _______________________________________________________

Date of Discharge: ________________________________________________________

Signed ____________________________________ Dated ________________________

Appendix A

Special Instructions Regarding Diet and/ or Exercise

Child’s name: ____________________________________________________________

Date: ___________________________________________________________________

Instructions: _____________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How long should Ultimate School-Agers follow these instructions: __________________

________________________________________________________________________

Signature of Parent: _______________________________ Date ___________________

Signature of Staff: ________________________________ Date ___________________