Royal Day Care Registration

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Relation to Child *

Mother

Father

Guardian

Name *

Home Phone *

Cell Phone *

Address *

Work

Work Phone *

Email Address *

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Cell Phone *

Relationship to Child *

Child's Personal Info

Name *

Birth Date *

YYYY

Child Lives With *

Mother

Father

Other:

Required

Desired Start Date *

YYYY

Type of Program *

Full Time (Monday to Friday, Morning to Afternoon)

Part Time (Please Specify Number of Days and Hours)

Drop In (Unscheduled and Unpredictable)

Required

Child's Medical Info

Health Care # (If out of province, please include province code) *

Physician's Name *

Physician's Phone *

Medical Concerns *

Diet Restrictions *

Allergies *

Is the child's immunization up to date? *

Yes

Required

Does your child receive medication on an ongoing basis? *

Yes

Required

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