Montessori Daycare Registration Form

Requested Start Date*

Child's Name*

First Last

Child's Address*

Child's Date of Birth*

Child's Gender*

Male
Female

Mother's Information

Mother's Name

First Last

Is the mother's address same as child's address?

Yes
No

Mother's Address

Mother's address if different from child's address.

Mother's Home Phone

Mother's Cell Phone

Mother's Email

Mother's Place of Work

Mother's Business Phone

Mother's Work Hours

Father's Information

Father's Name

First Last

Is the father's address same as child's address?

Yes
No

Father's Address

Father's address if different from child's address.

Father's Home Phone

Father's Cell Phone

Father's Email

Father's Place of Work

Father's Business Phone

Father's Work Hours

Child's Emergency Information

Child's Physician

Child's Physician's Phone

Child's Alberta Health Care Number*

Child's Allergies

Please provide TWO Emergency Contact People (excluding Parents) to whom child may be released.

Emergency Contact #1 Name*

Emergency Contact #1 Address*

Emergency Contact #1 Phone*

Emergency Contact #2 Name

Emergency Contact #2 Address

Emergency Contact #2 Phone

Daily Drop-off Time

: HH

MM

Daily Pick-up Time

: HH

MM

Child's Health History and Relevant Information

Immunizations Up to Date?*

Yes
No

Who has custody of the child?

If applicable, please provide a copy of the custody papers, please.

Medical issues

Medications given regularly

Date of disease / surgeries

Reaction to stress

Age(s) of siblings

Parent Method of Discipline

Prior Day Care Experience?

Yes
No

If yes to prior day care experience, please list

How did you hear about us?*

Person that referred you

Please explain how you heard about us?

"Get to know you" Information

Our staff like to form personal relationships with each child. By filling out this information, the teacher can prepare for his/her arrival in the classroom. Thank you!

Child's Culture

Other languages spoken

Family Cultural Celebrations

Favorite Cultural Foods

Diet Restrictions

Will you share cultural traditions / skills with us?

Yes
No

Naptime Routine

Fear / Anxieties

Bathroom / Diaper Routine

Ways your child expresses anger / frustration

How do you comfort your child?

Unique family situation that we should be aware of

Other information

Age Appropriate Developmental Goal*

We thank you for choosing our Centre for your child care needs. In order to help with your child’s optimal development, we would like you to share one age appropriate goal that you would like us to help your child achieve. We want your child to SUCCEED!