Registration Checklist

Student’s Name: ________________________________

Have I?

_____ Completed the registration package

_____ Paid the registration fee

_____ Signed all Waiver and Agreements

_____ Completed the Immunization Form

_____ Enclosed two copies of Form A

_____Enclosed two photocopies of my child’s Immunization Record

(please write child’s name and date of birth on each copy)

_____ Completed the Committee Preference Forms

(not required for non-participating parents)

Note: Pre-employment Health Form and Criminal Reference Check must be completed one month before the start of school and brought to the August General Meeting.

WAIVERS AND AGREEMENTS

All Parents and Participating Caregivers must read and sign the waivers and agreement. Financial Agreement:

I understand that 10 cheques post dated for the first of each month (September to June) must be remitted by the August/September general meeting. Payments can also be made quarterly, semi-annually, or in full. An NSF service charge will be applied for all returned cheques. Thirty days (30) written notice is required if you wish to withdraw your child from the Preschool. After the thirty days, any post-dated cheques will be returned.

Signature: Date: Sibling Waiver: I will not hold the Wellesley and District Cooperative Preschool responsible for any injuries sustained to any person who is not a registered member while taking part in any preschool function.

Signature: Date: Medical: I will not hold any person(s) in attendance at the Preschool responsible in case of accident, contraction of illness or loss of personal property. If, at any time, due to such circumstances, an accident or sudden illness occurs, and medical treatment is necessary, this may be given. I understand that any expense incurred for such treatment is my responsibility. (The above will enable a doctor to give the necessary treatment in case of an emergency when the parent cannot be contacted. It is understood that every effort will be made to reach the parent.)

Signature: Date: Photos: During the school year, students may be photographed (by the preschool). These photos are included in each child’s end of the year graduation booklet. Do we have permission to take photographs of your child for use within the centre

a) I CONSENT to my child being photographed for the above purposes.

Signature: __________________________________ Date:_____________________________________

b) I DO NOT CONSENT to my child being photographed for the above purposes.

Signature:_____________________________________ Date:_____________________________________

Photos taken by the preschool camera/tablet are also sent to parents via email (ie of what your child was participating in during the preschool day). In some of the photos your child may be with other children. Do we have your permission to send these photos to other parents. These photos are not posted on the internet or distributed in any other way.

a) l CONSENT to my child being photographed for the above purposes.

Signature: Date:

b) I DO NOT CONSENT to my child being photographed for the above purposes.

Signature:_______________________________________ Date:_________________________________________

Outings: Occasionally during the school year the students participate in short outings off the school premises, including walks in the neighbourhood and/or to the park.

a) I CONSENT for my child to accompany the class on these outings

Signature: Date:

b) I DO NOT CONSENT for my child to accompany the class on these outings

Signature: Date: Ontario Privacy Act: Permission must be obtained before we can print your name and telephone number in our school directory. Please select one of the choices below.

a) I CONSENT have my name and telephone number printed in the school directory. The information will only be used for the purposes of contacting me regarding school business

Signature: Date:

b) I DO NOT CONSENT to have my name and telephone number printed in the school directory.

Signature: Date:

(Name of Child Care Centre)

HEALTH & MEDICAL INFORMATION FORM

Dear Parent/Guardian:

Please provide any information regarding chronic medical problems (eg. diabetes, asthma, epilepsy, or other diseases) impairments or disabilities (eg. vision, hearing, speech) allergies (eg. drug, food, insect bites, pets and animals, environmental) routine medications (eg. Phenobarbital, Ritalin, etc.) – please indicate dosage and frequency

Child’s Name:

Chronic medical problemsYes No

Please describe:

Impairments and Disabilities Yes No

Please describe:

Allergies Yes No

Please describe:

Routine Medications Yes No

Please describe:

Date:

Note: This form is to be kept at the Child Care Centre only.

Information About Your Child

Please indicate your first and second choices for class preference. Spaces are allotted on a first-come first-served basis, but we strive to accommodate everyone.

Tuesday and Thursday a.m. ___________

Wednesday and Friday a.m___________

Duty Coverage

Full Participating ________ Partial Participating ________ Non-Participating ________ Who will cover duty days on behalf of your child? ______________________________

Has your child ever been in a preschool program? Yes _____ No _____

If yes, where? __________________________________________________________

Child’s friends: ___________________________________________________________

Sibling’s names and ages: __________________________________________________

Child’s fears: ____________________________________________________________

Favorite activities: ________________________________________________________

Does your child have any toileting needs? Yes _____ No _____ If yes, specify: __________________________________________________________

Does your child have any special emotional or social needs you feel the teacher should be made aware of? _______________________________________________________ _______________________________________________________________________

_______________________________________________________________________

What do you expect your child will gain from his/her preschool experience? _________ _______________________________________________________________________

_______________________________________________________________________

Are there any questions or concerns you have regarding membership in a cooperative preschool? ______________________________________________________________ _______________________________________________________________________

Health Information:

Does your child have any health conditions? Yes _____ No _____ If yes, specify: ___________________________________________________________

Does your child have any special requirements with respect to diet, rest or exercise? Yes _____ No _____

If yes, specify: ___________________________________________________________

Has your child contracted any communicable diseases? Yes _____ No _____ If yes, specify: ___________________________________________________________

If your child requires administration of medication (i.e. epipens and antihistamines), please submit a separate sheet signed by a parent or guardian with specific written instructions fir administration. (Please see policy on Administration of Medication in the Parent Handbook.)

Other:

Is there anything else you would like the teacher to know about your child? _________

_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

_______________________________________________________________________ _______________________________________________________________________

_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

REGISTRATION INFORMATION FORM

Child’s Name ______________________________________ Birth Date ________________________ FIRST LAST MONTH DAY YEAR

Address ______________________________________ Sex M F NUMBER STREET PLEASE CIRCLE

City ______________________________________ Email ________________________

Postal Code ______________________________________ Phone No. ________________________

MOTHER’S INFORMATION: FATHER’S INFORMATION:

Name ____________________________ Name ____________________________ FIRST LAST FIRST LAST

Home Phone ____________________________ Home Phone ____________________________

Cell Phone ____________________________ Cell Phone ____________________________

Address ____________________________ Address ____________________________ NUMBER STREET NUMBER STREET

City ____________________________ City ____________________________

Postal Code ____________________________ Postal Code ____________________________

Work Place ____________________________ Work Place ____________________________

Work Phone ____________________________ Work Phone ____________________________

Work Address ____________________________ Work Address ____________________________ NUMBER STREET NUMBER STREET

City & P.C. ____________________________ City & P.C. ____________________________

Custody Arrangements (please check if applicable):

Joint __________ Single __________ Sole __________ Legal Agreement YES NO

HEALTH INFORMATION:

Health Card No. ____________________________ Family Doctor ____________________________

Allergies ____________________________ Address ____________________________ NUMBER STREET

Required Medications ____________________________ City & P.C. ____________________________

____________________________ Phone Number ____________________________

EMERGENCY CONTACT: This emergency contact (other than the parent) needs to be reachable during preschool hours, live near by, and must understand the potential need for them to be called upon.

Name and relationship to child ________________________________________________________________

Address ____________________________ Phone No. ________________________ NUMBER STREET

City and Postal Code ____________________________ Alternate Phone No._______________________

Other adults authorized to pick up child: _________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Notice with Respect to the Collection of Personal Information

(Freedom of Information and Protection of Privacy Act)

Any person employed by a licensed day nursery or employed by or associated with a licensed private-home day care agency must complete this form.

In administering and enforcing the Day Nurseries Act (DNA), Ministry of Education program advisors and the Director under the DNA may collect and review personal information about staff employed by a licensed day nursery or employed by or associated with a licensed private-home day care agency under the authority of s.16 (4) of the Day Nurseries Act (DNA) and s.58, 59, 60, 61 and 62 of O. Reg. 262 under the DNA to ensure that the day nursery or private-home day care agency operator is complying with the DNA and O. Reg. 262.

This form is required to be kept for the ministry’s review at the child care centre where you are employed or the head office of the private-home day care agency.

Your personal information may be provided by your employer in connection with an application for approval of a Supervisor, a person to take the place of a Registered Early Childhood Educator or approval of a Private-Home Day Care Visitor, if applicable.

Information collected in the licensing process about Registered Early Childhood Educators may be shared with the College of Early Childhood Educators if necessary for the enforcement of the Early Childhood Educators Act, 2007.

Questions concerning the direct or indirect collection of personal information may be addressed to the:

Child Care Quality Assurance and Licensing Branch Early Learning Division Ministry of Education 900 Bay Street, 24th floor, Mowat Block Toronto, ON M7A 1L2 416-314-8373

Name (print) ______________________________________________

Signature ______________________________________________

Date ______________________________________________

A copy of the form should be given to the person who completes it.

Wellesley & Disctrict Cooperative Preschool 157 David Street Wellesley Mennonite Church

Wellesley, Ontario, N0B 2T0

519-656-3132 wellesleypreschool.coop@gmail.com

Date: _________________

To Whom It May Concern:

Wellesley and District Cooperative Preschool is committed to the growth

and safety of its children.

By law, those who work with children in a preschool setting must have a

criminal record done annually. Please accept this letter as a request to

conduct a criminal record check on ______________________________

to enable them to assist in the capacity as a volunteer with our Preschool.

Thank you,

Wellesley & District Cooperative Preschool Executive

PRE-EMPLOYMENT HEALTH FORM FOR

EMPLOYEES / PROVIDERS / VOLUNTEERS in Child Care Centers

This information will be kept on file at the child care setting or designated location. It will be used to maintain a cumulative record of

immunization status and to identify persons with health problems. This information may also be shared with Region of Waterloo Public

Health if an outbreak occurs.

Last Name: First Name:

Home Address:

City: Postal Code:

Home Phone ( ) __ __ __ - __ __ __ __ Work Phone ( ) __ __ __ - __ __ __ __ ext. _______

Child Care Centre: Home Child Care

General Instructions: a) Employees/providers are required to have up-to-date immunization, tuberculosis screening history and to

complete this form with information on infectious diseases and general health history as indicated.

b) Volunteers are required to complete this form to provide information regarding immunization, tuberculosis

screening history, infectious disease history and general health information. There is no requirement that

these be up-to-date, although it is highly recommended. Parent co-op volunteers are included in this

category. TB skin testing is not recommended for volunteers who expect to work less than 150 hours/year

(approximately one half day per week).

Please read and complete the following sections:

IMMUNIZATION HISTORY DATE It is very important that any persons working with children have up-to-date immunization. (Year/Month/Day)

Tetanus Diphtheria Pertussis (i.e., Adacel™) - funded for adults as a one time adult dose, safe

_____/_____/_____ any time after a tetanus vaccine; no need to wait 10 years

If Tetanus, Diphtheria, Pertussis was completed more then 10 year ago:

Tetanus Diphtheria – should receive a booster every ten year (after receiving tetanus, diphtheria, _____/_____/_____ pertussis.

Measles, Mumps, Rubella (One dose after 1st birthday. Not required if born prior to 1970 or if

_____/_____/_____ has lab-documented immunity to all three infections. Note: since Aug/11 a second dose of MMR is recommended for young adults (18-25 years) and persons who received the killed measles vaccine in

1967-1970.)

Polio Yes □ No □ (Initial series given in childhood only - adult boosters are not required except in certain situations.)

Routine adult immunization is available free of charge from your physician if you require a booster.

Hepatitis B Yes (series completed) □ (Immunization against Hep B may be beneficial but is not a requirement. Vaccine may be purchased

No □

through your family physician.)

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Page 2 TUBERCULOSIS (TB) SCREENING HISTORY Please complete the following screening tool:

Have you come to Canada in the past 5 years from one or more of the following regions? Yes No

• Asia (including Middle Eastern Countries) • Africa • Central and South America • Eastern Europe

Have you spent more than 3 consecutive months in one or more of the following regions in the last 5 years? Yes No

• Asia (including Middle Eastern Countries) • Africa • Central and South America • Eastern Europe

Do you have any of the medical conditions listed below? Yes No

• Kidney Problems

• HIV/AIDS

• Diabetes

• Silicosis

• Cancer

Do you take immune suppressing medications? Yes No

Have you been exposed to someone with tuberculosis in the past? Yes No

If you answered YES to any of the above questions TB Skin Testing is required.

Complete testing section below.

If you are unsure how to answer any of the above questions, please contact your family physician or call Region of Waterloo

Public Health at (519) 575-4400.

A one step (not two step) TB skin test is required for those child care providers Date of test

Result (in and employees who have answered YES to any of the above TB screening mm)

questions.

The testing should be completed within six months prior to commencing employment and is strongly recommended for volunteers who expect to work more than 150 hours/year (one half day per week).

______/____/____

Note: Employees working at multiple sites or changing employment in the child care sector within

Waterloo Region only require one TB skin test ever; therefore the 6 month requirement would apply

only to the first job.

Chest X-ray ______/____/____

If needed due to a positive skin test reaction as recommended by the health care practitioner at the

time of testing. A repeat chest x-ray is not required within six months of hire. TB skin test may be obtained through your family physician (will charge a fee as advised by the College of

Physicians and Surgeons), a local walk-in clinic (fees vary) or can be arranged by calling Region of

Waterloo Public Health at 519-575-4400 (fee will also be charged).

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INFECTIOUS DISEASE HISTORY

Immune

Working with children may expose persons to a variety of infectious diseases. It

NO

UNKNOWN

(history of disease or

is helpful for a person to know if he/she is immune to certain childhood diseases

for his/her own protection (as some infections produce more severe symptoms in immunity from vaccine)

adults or are a concern to a fetus if a person is pregnant). Chickenpox If you are unsure, a blood test can be done to determine immunity. A chickenpox

vaccine is now available at your family physician, or contact Region of Waterloo

Public Health for more information at 519-575-4400

Rubella (German Measles) All women of childbearing age should know if they are immune to rubella prior to a

pregnancy. A blood test will determine immunity; a routine test during pregnancy.

Please consult with your physician if you wish to determine your immunity to these infections.

GENERAL HEALTH YES NO

I am presently in good health.

Any limitations to participation?

Comments:

Signature of Employee / Provider / Volunteer: Date:

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