Child's name: *

Month Day Year

Day of Birth: * January February March April May June July August September October November December 12345678910111213141516171819202122232425262728293031 202120202019201820172016201520142013

Gender: *  Female   Male

Does your child have any medical conditions the staff should be aware of (i.e. allergies)?

Indicate any special medical attention your child may require:

Is your child's immunization up to date? *
(for clients subsidized by The Region of Waterloo Child Care Subsidy, please answer yes or no)

Yes   No Declined

For possible future advertising we need consent from parent to include photographs and video of children *

Yes   No

Select program date(s): *

If you have a promotion code, enter it here:

Contact name(s): *

Relationship: *

Home phone: *

Work phone: