Ultimate School-Agers Enrollment Form
Please fill in this form and submit it to us to secure your spot. We will be in touch shortly to confirm details and schedules.
Thank you for choosing to join our family.
NOTE: THIS FORM NEEDS TO BE FILLED IN ONCE PER CHILD (E.G. 2 FORMS FOR 2 CHILDREN)
NOTE: A REPRESENTATIVE FROM OUR PROGRAM - WE WILL BE IN TOUCH WITH YOU SHORTLY TO GO OVER YOUR ENROLLMENT FORM.
NOTE:
Sincerely,
The Ultimate School-Agers team
289-685-2343
* Required
Child's Last Name
*
Your answer
Child's First Name
*
Your answer
Sex
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Male
Female
Birth Date
*
MM
/
DD
/
YYYY
School Attending
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NOTE: IF YOUR SCHOOL IS NOT LISTED BELOW, WE DO NOT CURRENTLY SERVICE IT ON OUR BUS RUN
PRESCHOOL
Lydia Trulls
MacGillivray
Mother Teresa
Courtice North
Good Shepherd
OTHER - N/A
Standard Days Attending (minimum 3 days per week required)
MON
TUES
WED
THURS
FRI
NOT NEEDED
BEFORE AND AFTER
BEFORE
AFTER
PRESCHOOL FULL DAY
PRESCHOOL AM ONLY
PRESCHOOL PM ONLY
PRESCHOOL 830AM-300PM
MON
TUES
WED
THURS
FRI
NOT NEEDED
BEFORE AND AFTER
BEFORE
AFTER
PRESCHOOL FULL DAY
PRESCHOOL AM ONLY
PRESCHOOL PM ONLY
PRESCHOOL 830AM-300PM
Home Address
*
MAKE SURE THIS IS COMPLETE WITH THE POSTAL CODE
Your answer
Guardian #1 Full Name
*
Guardian #1 must have the same home address as the child
Your answer
Guardian #1 Relationship
*
Mother
Father
Grandmother
Grandfather
Other:
Guardian #1 Phone Number
*
Your answer
Guardian #2 Full Name
Guardian #1 must have the same home address as the child
Your answer
Guardian #2 Relationship
Mother
Father
Grandmother
Grandfather
Other:
Clear selection
Guardian #2 Phone Number
Your answer
Guardian #1 email address
*
Your answer
Guardian #2 email address
Your answer
Is there an Alternate Emergency Contact #1?
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If YES, then please provide the full name, phone number and relationship
NO
Other:
Is there an Alternate Emergency Contact #2?
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If YES, then please provide the full name, phone number and relationship
NO
Other:
Please list any other names of people who your child can be released to.
Your answer
Is there anyone we should NOT release your child to under any circumstance?
Your answer
Family Physician's name, Phone Number, Address
*
Your answer
How did you first hear about us?
*
Friends/Family
Internet
Church
Billboard Sign
Other:
Does Ultimate School-Agers have permission to take pictures of your child?
*
Yes
No
Does your child have any food allergies? If YES then provide details below.
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No
Other:
Does your child have any drug allergies? If YES then provide details below.
*
No
Other:
Does your child have any environmental allergies? If YES then provide details below.
*
No
Other:
Is your child at risk of an anaphylactic reaction due to the allergy?
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If YES you need to fill out our anaphylactic form
Yes
No
Please list signs of any medical conditions, communicable diseases, special medical equipment your child has that we should be aware of.
Your answer
Any dietary restrictions we should be aware of?
*
NO
Other:
Anything else you would like us to be aware of?
For example, 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? Any specific activities your child DOES like or DOES NOT like to do?
Your answer
Administration of Potassium Iodide
*
Because of our close proximity to the Darlington Nuclear Power Plant we need to obtain consent from you to administer a potassium iodide (KI) pill to your child. If an accident occurs at Darlington Nuclear Power Plant there is a chance radioactive material can be released. This radioactive material will be absorbed by the thyroid gland at the front of the neck. Taking the KI pill can minimize the amount of radiation taken up by the thyroid.There is a good chance that evacuation procedures will occur long before there is any risk of radiation. The KI pills are in place as an added protection for all of us. Should you have any questions regarding the KI pills please contact the Durham Region Health Department at (905)723-3818.There is a chance that an individual may have an allergic reaction to iodine. It is imperative if you inform us if you have any suspicion of your child having an allergy to iodine.According to the age group of children at Ultimate School-Agers, all the children will receive 1 pill. In case of a nuclear accident I, give Ultimate School-Agers permission to administer an iodine pill to my child.
GIVE PERMISSION
DO NOT GIVE PERMISSION
Is there a custody order regarding your child? If so please provide details such as fees split percentage, etc.
*
NO
Other:
Bussing Policy
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Ultimate School-Agers takes transporting your child (ren) seriously and "we know each of us has the goal of safety in mind. To minimize the opportunity or misfortune we ask that you read and comply with the following regulations: Every time your child does not require bussing you must inform us immediately. We do have staff at every school but it is essential you let us know by 2PM if your child does not need us to pick them up. We have several schools to pick up from and each has a predetermined arrival and departure time. Therefore, you must tell your child that they must get ready and go to the pickup area immediately as we cannot afford a delay.• We are on a tight schedule and we cannot afford to wait for more than five minutes at a stop. This again is why it is essential to inform us and to let your children know the importance of being on time.• If the bus is ever late and no staff is able to make it to the school at the bell time, we will inform the school and your child will be asked to go to the office. Each school has a list of children that attend Ultimate School-Agers.• If your child has a detention or after school activity, it is your responsibility to pick your child up from school.• Children must follow the bus rules at all times. Repeated lack of respect for the rules could result in being suspended from the bus.• If you continually fail to inform us that your child does not require bussing, then your child may be suspended from the bus. • All the staff have their cell phones during school runs. If you need to contact us in case of an emergency, please call Ultimate School-Agers, phone number 289-685-2343, and they in turn will contact the staff responsible for your child's school. I have read and understood the above rules and regulations regarding Ultimate School-Agers bussing policy.
ACCEPT
Handbook Review and Acceptance - Click here
https://www.ultimateschoolagers.com/uploads/7/6/2/8/76285121/parent_handbook.pdf
*
ACCEPT
As a Health Department requirement, we need all parents to fill in and return this form
goo.gl/fXc94U
to our center to complete the enrollment documentation process.
if you have chosen not to immunize due to medical or religious reasons to contact our center for appropriate paperwork.
I have printed and filled in this form and will return it to USA center
I will contact USA center to fill in paperwork for no immunization choice
Clear selection
What is your child's start date?
*
For existing parents updating their file, please enter approximately when you joined us.
MM
/
DD
/
YYYY
Does your child have a medical diagnosis for ADHD, Autism, ODD or similar?
*
If YES then a copy of our Individual Support Plan form MUST BE PRINTED, FILLED IN AND RETURNED TO US PRIOR TO THE FIRST DAY OF SERVICE. Link here:
https://www.ultimateschoolagers.com/uploads/7/6/2/8/76285121/policy_-_individualized_support_plans_and_forms_w_snr_form.pdf
Yes
No
By signing (typing) your FULL NAME below, you hereby attest to the accuracy of the information provided above, accept the policies outlined here and in our handbook and request enrollment of your child in our program. Note: Only the name of Guardian #1 or #2 are considered valid signatories.
*
Your answer
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