day care copy - lpband.ca · Rubella: Doctor’s Signature Nurse’s Signature Health Record:...

Registration Forms

Long Plain MikinaakDay Care Facility

Child’s Data

Identification of Parents or Guardians

Child’s Name: Date of Birth:

Gender: Language Spoken at Home:

Guardian’s/Parent’s Phone Numbers:

Home:

What Day Care hours will you need for your child?

Has your child previously attended a day care facility?

If yes, what is the name of that facility?

Mother’s name:

Address:

Place of employment:

Telephone (Work):

Cell Phone:

The Person who has custody of this child is:

Work:

Emergency:

Father’s name:

Address:


Telephone (Work):

Cell Phone:

Address:


Telephone (Work):

Cell Phone:

Mother Father Grand Parent Guardian

Male Female

Yes No

Grandparent’s name:

Registration Form

LONG PLAIN FIRST NATIONMIKINAAK DAY CARE FACILITY

DD MM YYYY

Date: DD MM YYYY

1

LONG PLAIN EMPLOYMENT & TRAINING110-5010 Crescent Road West, MB R1N 4B1Website: www.lpet.ca

Phone: (204) 857-7474Fax: (204) 857-7480

E-mail: [email protected]

Other People Responsible for this Child

Information about the child:

Do you authorize other people to drop off and pick up your child?

If yes, please provide the following information:

Full legal name:

Full legal name:

Full legal name:

How would you describe the child’s behavior (calm, active, shy, etc.) please provide us with a small description:

Does your child have activities that he/she particularly enjoys? (Books, Puzzles, Music, etc.)Please provide us a list of those activities.

What does your child like to eat?

What action do you take if your child does not want to eat?

What is the word your child uses for urination?

Phone Number:

Phone Number:

Phone Number:

Yes No

Registration Form


2


Phone: (204) 857-7474Fax: (204) 857-7480


Is your child is comfortable playing with other children?

Does your child take an afternoon nap?

If yes, at what time?

Does your child wear cloth diapers/ pampers?

What is the word your child uses for bowel movement?

Does your child need to be reminded to go to washroom?

Does your child have any allergies?

Other allergies include:

Does your child have any visual problems?If yes please provide information:

Does your child have any hearing problems?If yes please provide information:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Food allergies include:

Medication allergies include:

Does your child have any physical problems/ difficulties?If yes please provide information:

Does your child have any specific difficulties? (Fear of dark, noise, crowds, etc.) If yes please provide information:

Registration Form


3


Phone: (204) 857-7474Fax: (204) 857-7480


Does your child have any special health or medical concern?If yes please provide information:

Are your child’s immunizations are up to date?:

Do you have any suggestions for your child care provider to make your child’s day an enjoyable experience?

Signature of Parent/Guardian Date

DateSignature of Director

**** The following attachments are to be signed, witnesses and returned to the director as soon as possible. ****

Yes No

Yes No

Registration Form


DD MM YYYY

DD MM YYYY

4


Phone: (204) 857-7474Fax: (204) 857-7480


Compliance

And

Forms**** The enclosed sheets and Forms must be completed. ****

If a parent/guardian is unsatisfied with a Director’s decision, the parent/guardian has an option to appeal in writing to:

Long Plain Chief & Council

The following are agreements and forms that need to be filled out, signed and returned to the Day Care as soon as possible.

1. Medical Consent Form

Attachments:

5. Contribution Agreement4. Compliance Sheet3. Medical Report2. Emergency Contact Numbers


5


Phone: (204) 857-7474Fax: (204) 857-7480


Medical Consent Form

I give permission for my child _______________________________ that in the event of an emergency when I cannot be reached, to receive such medical procedures as deemed necessary by my physician:

Doctor: Address:

Phone Number:

Or by any other physician selected by the Long Plain First Nation Mikinaak Day Care. I will accept financial responsibility (if any) for an emergency medical care necessary.

Child’s Manitoba Medical number:

Child’s 9 digit number:

Child’s treaty number:

Parent/Guardian Signature Date

Consent Form:


DD MM YYYY

6


Phone: (204) 857-7474Fax: (204) 857-7480


Primary care-giver:

Telephone (Work):

Telephone (Home):

Cell Phone:

Telephone (Work):

Telephone (Home):

Cell Phone:

Telephone (Work):

Telephone (Home):

Cell Phone:

Telephone (Work):

Telephone (Home):

Cell Phone:

Partner:

Emergency Provider: Back-up:

***It is important that we are provided with the above numbers***

Emergency Contacts Numbers:

Registration Form


7


Phone: (204) 857-7474Fax: (204) 857-7480


To the Parents/Guardians:

It is necessary that we have a record of your children’s health status.Please have your doctor or our public nurse fill in this form.

Last Name: Given Names:

Date of Birth: Name of Parent/Guardian:

Name of Physician: Physician’s Phone number:

The above child has had the following communicable Diseases. Check the Box and provide the dates in which the child had the communicable disease.

Chicken pox:

Mumps:

Ribeola:

Rubella:

Whooping Cough:

Immunization Record (Please provide dates)

D.P.T

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Polio (Oral Sabin):

Rubeola:

Rubella:

Doctor’s Signature Nurse’s Signature

Health Record:

Pre-School Health Record


8

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

DD MM YYYY

DD MM YYYY

DD MM YYYY

DD MM YYYY

DD MM YYYY

DD MM YYYY

DD MM YYYY

DD MM YYYY

DD MM YYYY

DD MM YYYY


Phone: (204) 857-7474Fax: (204) 857-7480


I have Read and reviewed the “Parent Policy Manual”.

Therefore, I hereby agree to comply with the policies and regulations of the LONG PLAIN FIRSTNATION MIKINAAK DAY CARE CENTER, regarding all items specified in the Parent Policy Manual.

I hereby agree to notify the Day Care in writing, two (2) weeks in advance of withdrawal of my child/ children, or I will be responsible for the payment of the above said two (2) weeks.

Date

Parent/ Guardian Parent/ Guardian

Witness Director of Day Care

Compliance Sheet


DD MM YYYY

9


Phone: (204) 857-7474Fax: (204) 857-7480


PARENT CONTRIBUTION

1. There is a parent Contribution of the following;

Working Parents $10.00/Day with two child $5.00/Day

Students $7.50/Day with 2nd Child $3.75/Day

2. A verbal warning is given by the agency’s Director to the Parents after one week of Overdue payment.

3. Parent fee will be billed every two weeks by the 15th and 30th of every month.

4. Parent fees will not be allowed t exceed $200.00 or Child/Children will be withdrawn from Daycare.

5. A written notice will be sent after two(2) weeks of overdue fees.

I agree to this late payment procedure schedule:

Signed this_________________day of _____________ in the year_______________.

Parent’s/Guardian’s Signature Witness

Director

Parent Contribution:


10


Phone: (204) 857-7474Fax: (204) 857-7480


day care copy - lpband.ca · Rubella: Doctor’s Signature Nurse’s Signature Health Record:...

Documents

Transcript of day care copy - lpband.ca · Rubella: Doctor’s Signature Nurse’s Signature Health Record:...