Ultimate School-Agers Enrollment Form

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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

Child's First Name *

Child's Last Name *

Sex *

Male

Female

Birth Date *

YYYY

School Attending *

CAMP

PRESCHOOL

Is your child toilet trained? *

Most applicable for our preschool children

Yes

Standard Days Attending (minimum 3 days per week required)

PLEASE DO NOT LEAVE THIS SECTION BLANK

MON

TUES

WED

THURS

FRI

NOT NEEDED

PRESCHOOL FULL DAY

Home Address *

MAKE SURE THIS IS COMPLETE WITH THE POSTAL CODE

Guardian #1 Full Name *

Guardian #1 must have the same home address as the child

Guardian #1 Relationship *

Mother

Father

Grandmother

Grandfather

Other:

Guardian #1 Phone Number *

In format 123-456-7890 ONLY

Guardian #2 Full Name

Guardian #1 must have the same home address as the child

Guardian #2 Relationship

Mother

Father

Grandmother

Grandfather

Other:

Clear selection

Guardian #2 Phone Number

In format 123-456-7890 ONLY

Guardian #1 email address *

Guardian #2 email address

Is there an Alternate Emergency Contact #1? *

If YES, then please provide the full name, phone number and relationship

Other:

Is there an Alternate Emergency Contact #2? *

If YES, then please provide the full name, phone number and relationship

Other:

Please list any other names of people who your child can be released to.

Is there anyone we should NOT release your child to under any circumstance?

Family Physician's name, Phone Number, Address *

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

Does your child have any food allergies? If YES then provide details below. *

Other:

Does your child have any drug allergies? If YES then provide details below. *

Other:

Does your child have any environmental allergies? If YES then provide details below. *

Other:

Is your child at risk of an anaphylactic reaction due to the allergy? *

If YES you need to fill out our anaphylactic form

Yes

Please list signs of any medical conditions, communicable diseases, special medical equipment your child has that we should be aware of.

Any dietary restrictions we should be aware of? *

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?

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. *

Other:

Handbook Review and Acceptance - Click here https://www.ultimateschoolagers.com/signup.html *

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.

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

You agree to make a deposit equivalent to 2 weeks fees per our fee schedule upon confirmation of space availability by the center *

YES

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. *

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