Child Care Information Form

Membership Details

Membership Status

Member

Non-Member

Member barcode #

Child Details

Child's Name

Child's Birthdate

Parent/Guardian Details

Email Address

Parent/Guardian's Name(s)

Cell Phone Number(s)

Address

Postal Code

Alternative Pick up Information

Alternative Emergency Contact

Relationship

Cell Phone Number(s)

Health Information

Child's Doctors Name

Child's Doctors Phone Number

Child's Doctors Address

Are Immunizations up to date?

Yes

Does your child have allergies?

Yes

Please indicate allergies, reactions and medications below

Does your Child have any exceptional medical needs? ie. Diabetes, Asthma, etc. If yes, you will be given a care plan to complete for our records.

Yes

Do we have permission to take your child outside? (weather permitting and on MNPCSC property)

Yes

Policy Approval

LATE PICK UP POLICY: I acknowledge that Child Care time is charged in 2 hour blocks and If I go over my booked time I understand I will be charged $1 for every minute I am late and the fee will be charged to my credit card on file.

Yes

CANCELLATION AND PICK UP POILCY: I acknowledge that I have read the Child Care Cancellation and Pick up Policy stating that if I need to cancel, I will need to email by 7:00am the day of booking or via the Online Portal.

Yes

I have read the Toileting Policy and give permission for my child (named above) to be diapered/toileted or changed accordingly.

Yes

Date / Time

Child Care Information Form

Membership Details

Child Details

Parent/Guardian Details

Health Information

Policy Approval

Schedules

Programs

Facility

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