Child Information Form

ALL INFORMATION & SIGNATURE REQUESTED ARE MANDATORY.
Your child will not be allowed to participate in the program until all necessary information is provided. Please make sure all information is current & correct.

Child’s Information

First Name *

Middle Name

Last Name *

House / Apt. #

Street *

Postal Code *

Name Commonly Used

Date of Birth *

Gender *

Male Female Other

Languages Known / Spoken

Parent / Guardian 1

First Name *

Last Name *

Relationship to Child *

House / Apt. #

Street *

Postal Code *

Home Phone *

Cell Phone

Can receive text messages?

Yes No

Workplace / School Name

Work Phone

Work Address / Bldg #

Street

City

Parent / Guardian 2

Parents live in separate dwellings — fill in Guardian 2’s separate address & contact details below

First Name

Last Name

Relationship to Child

House / Apt. #

Street

Postal Code

Home Phone

Cell Phone

Can receive text messages?

Yes No

Workplace / School Name

Work Phone

Work Address / Bldg #

Street

City

Contact Email

Only one email address will be kept on file for all school communications.

Email Address *

Designated Emergency Contact

Must be an adult 18 years of age or older. This is a person we can contact AND release your child to in case of illness or emergency if you are not available.

First Name *

Last Name *

Relationship to Child *

House / Apt. #

Street

City

Home / Cell Phone *

Email

Other People Authorized to Pick Up Your Child

Must be an adult 18 years of age or older.

Person 1

First Name

Last Name

Relationship to Child

Home Phone

Cell Phone

Person 2

First Name

Last Name

Relationship to Child

Address / Bldg #

Street

City

Home / Cell Phone

Work Phone

Is Person 2 allowed to pick up your child in a non-emergency situation?

Yes No

Medical Information

Family Health Number (6 digits)

Personal Health Number (9 digits)

Child’s Doctor

Doctor’s Phone Number

Medical Conditions / Medications (given at home or at Nursery School)

Toileting Details

All enrolled children are required to independently use the washroom facilities. Indicate if your child may need additional assistance:

Prompts or reminders Fasteners, buttons, or zippers Wiping and / or washing hands

Family Situations & Previous School Experience

Names & ages of siblings (and school of attendance):

If your child attended a nursery or similar program, please list:

Allergies

Does your child have allergies to food, animals, medication, etc.? *

Yes No

Please describe the allergies:

Are the allergies life-threatening (Anaphylaxis)?

Yes No N/A

Does your child have an Epi-Pen to leave at nursery?

Yes No N/A

Asthma

Does your child have Asthma? *

Yes No

Known Triggers:

Does your child have an inhaler?

Yes No N/A

Asthma medications:

Special Conditions & Cultural Requirements

Describe any physical, emotional, developmental, cultural or other conditions relevant to the care of your child:

Are there any cultural, religious or personal requirements or restrictions we should be aware of?

Yes No

If yes, please describe:

Does your child have any emotional, developmental (e.g. speech, motor skills delay, etc.) or other conditions?

Yes No

Is your child currently receiving services from specialists (speech pathologist, child development, occupational/physical therapist)?

Yes No

If yes, please describe:

Does your child require additional support staff to attend Nursery School?

Yes No

If yes, please describe:

Emergency Medical Transportation and Treatment

If, at any time, medical treatment is necessary due to a serious injury or sudden illness, I authorize James Nisbet Nursery School Inc. to take all emergency measures deemed necessary for the protection of my child while in the care of the Nursery School. I give permission for my child to receive medical attention deemed necessary by my child’s doctor or other medical personnel. I understand this may involve transportation to the hospital in a private vehicle or ambulance. I understand the Nursery School will make every attempt to contact me and any expense incurred for such treatment, including ambulance fees, is my responsibility.

Date *

Parent’s Name (please print) *

By checking this box I confirm I have read and agree to the Emergency Medical Transportation and Treatment authorization above, and I acknowledge that my typed name above serves as my electronic signature. *

A confirmation email will be sent to the address provided. The school will follow up with you directly.