Re-RegistrationCaboose Club Re-Registration Basic InformationEmergency ContactsConsent and AgreementEmergency and Permission CardCaboose Club Re-Registration FormREGISTRATION INFORMATIONChild’s Full Name *Last Day of Care *————————Grade *School Year for Registration (e.g., YYYY-YYYY) *————————Date of Birth *I, have reviewed my child’s file and agree that there are no changes to be made in any area of the registration form and all information is up-to-date.Signature * Do you need to add people to the authorized pick-up list? *YesNoThe following people can be added to the authorized pick-up list: Name Work Phone Relation Add Remove–––Emergency Contacts(if we cannot reach you, who can we call in an emergency, or for advice or pick-up?)Full Name *Full Name *Full Name Phone *Phone *Phone Work Phone *Work Phone *Work Phone Relation *Relation *Relation Persons NOT Permitted Access to ChildAre there persons who are NOT permitted access to child? *YesNoPersons Not Permitted Full Name *Phone *Add RemoveConsent and Agreement:The provided information is true and current to the best of my knowledge:Parent 1 Signature * Enrollment Date *Parent 2 Signature * Enrollment Date *Emergency Contact and Permissions CardChilds Photo * Drop your file here or click here to upload Parent/Guardian #1 *Parent/Guardian #2 *Childs Name *Date of Birth *Parent Work Phone #1 *Parent Work Phone #2 *Address *Address Line 1Sex *MaleFemaleHome Phone *–Emergency Contact *Medical Condition *YesNoRelation *Childs Doctor *Work Number *Doctors Phone *Describe Medical Conditions *Date of most recent tetanus shot: *Child has known allergies? *YesNoMedical Number (PHN) *Child Allergies *Blood Type *Additional Information Permission Form1. It is the facility’s policy to notify the parent when a child is ill or requires medical attention. If we are unable to contact the parent and the child needs immediate medical help, parental consent is necessary for facility staff to take appropriate action on behalf of the child. Your consent will accompany the child to the emergency room.2. I authorize the staff at the CABOOSE CLUB child care facility to call a physician, take my child to the nearest emergency centre or summon an ambulance for emergency medical aid should the person(s) in attendance feel such services are required and I cannot be contacted by phone. If such an emergency should arise, I shall be notified as soon as possible. I agree that any cost incurred for such services shall be the sole responsibility of myself.Parent/Guardian #1 Signature Date Parent/Guardian #2 Signature Date NamePreviousNextSubmit Registration
