HAMMONDS PLAINS CHILDREN'S CENTRE
#1 Yankeetown Road, Hammonds Plains, NS
B3Z 1K7 Canada, http://www.turbokids.ca
Ph +1 902 835 1804, Fax +1 902 835 1484
Application Form
Date of application
Child's name
Child's date of birth
Parent/Guardian's (Mother) name
Parent/Guardian's (Father) name
Address, Postal Code
Home phone number
Work phone numbers
Email address
First day at Hammonds Plains Children's Centre
1. Childcare
___ Monday ___ Tuesday ___ Wednesday ___ Thursday ___ Friday ___
AM ___ PM ___ Lunch ___ Before School ___ After School ___
2. Who to contact in case of an emergency
Person to contact other than parent/guardian (Name, phone, relationship)
Second Person to contact other than parent/guardian (Name, phone, relationship)
3. Persons authorized to call for the child
Person other than parent/guardian (Name, phone, relationship)
Second Person other than parent/guardian (Name, phone, relationship)
Family Doctor (Name, phone, address)
Child's health card number
4. Emergency medical treatment consent
I/we give authorization for my/our child to receive necessary medical treatment and/or be taken to hospital if I/we cannot be reached
Parent/guardian (Mother) signature
Parent/guardian (Father) signature
5. Consent
I/we give authorization for my/our child to go on outings with Hammonds Plains Children's Centre, providing they are accompanied by qualified staff
Parent/guardian (Mother) signature
Parent/guardian (Father) signature
I/we give my/our consent for my/our child's picture to be the on HPCC website. I realize that there will be no names posted on the website
Parent/guardian (Mother) signature
Parent/guardian (Father) signature
6. Personal Information and Electronic Documents Act
Hammonds Plains Children's Centre will not disclose any information given on this application form. All information will be kept confidential.
2006-11-03 - Hammonds Plains Children's Centre Inc.