Online Registration – Kidz Junction Daycare & After School Care

Online Registration Form

Child's Name

Nickname or any preferred name:

Gender

Male Female

Date of Birth

Address

Alberta Heath Care Number

Physician's Name

Physician's Contact Number

Is your child's immunization up to date?

Yes No

General state of health

Any known allergies

Symptoms/reactions of allergies

Medication required if any

Are you concerned that you child may be prone to any type of allergies? Please describe:

Does your child have any medical conditions which we should be made aware of:

Does your child have any speech, hearing or visual problems? Please describe:

Would there be any restriction to play or activities?

Name

Marital Status

Address

Phone Number