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Kindercare Registration
Please complete all required fields!
Email Address
(*)
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Registering For:
(*)
Kindercare Full Time
Kindercare Part Time (Contact Nicole at 780-965-9147 for part-time availability)
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Name of Child:
(*)
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Child's Birthdate:
(*)
Day
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Month
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Year
2014
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2019
2020
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What school is your child attending?
Note: Transportation from Parkview Elementary is provided.
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Mothers Name:
(*)
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Fathers Name:
(*)
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Address:
(*)
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Child's Address if different from above:
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Mom Cell Number:
(*)
123-456-7890
Mom Work Number:
123-456-7890
Home Phone Number:
(*)
123-456-7890
Dad Cell Number:
(*)
123-456-7890
Dad Work Number:
123-456-7890
Child resides with (check applicable box(s)):
(*)
Mother
Father
Guardian
Shared Custody
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Childs Gender:
(*)
Male
Female
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Community League you live in:
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Membership Number:
Valid Membership Required
Care Giver (if applicable):
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Care Giver Cell Number:
123-456-7890
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Medical Information
Doctor's Name:
(*)
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Phone Number:
(*)
123-456-7890
Are your child's immunizations up to date?
Yes
No
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List childhood diseases to date:
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Please list any allergies, on-going medical medications, or medical problems that the Kindercare staff should be aware of:
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*** IN CASE OF EMERGENCY, IF PARENT OR GUARDIAN IS NOT AVAILABLE, PLEASE CONTACT: ***
Name:
(*)
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Relationship:
(*)
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Phone Number:
(*)
123-456-7890
Cell Number:
(*)
123-456-7890
Address:
(*)
Please include postal code.
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