Office Use Only: Information Required: __________________________ Date/Time Received:____________________________
COLWOOD PRESCHOOL 2016-2017
Registration Date: ____/_____/_____ Pd. Reg Cheque #____ Cash ____ Start Date: _____________
M
D
Y
Pd. September’s fee _________ Payment method:___________
(4 yr. old) $220/month
(3 yr. old) $140/month
(3/4 year old) $130/month
Class Preferred:
____ M/WF am (9:00-1:00)
___ T/T am (9:00-12:00)
____ T/T pm (12:30-3:00) pending
Child’s Full Legal Name: First _____________________ Last _________________________
Birth date: ______ / ______ / ______
M
D
Y
Gender: Male ________ Female _______
Child’s First Language ___________________________ Second Language: __________________________
Parents/Guardians: Dad: _____________________
Mom: _____________________
Parent/Guardian Address: ____________________________________ City____________ Postal Code __________
Home Phone:_______________ Email Address: __________________________________
Father Occupation: ____________________
Business Number: ________________ Cell Phone: _______________
Mother Occupation: ____________________
Business Number: __________________ Cell Phone: ______________
Marital Status: ___ Married
___ Divorced ___ Separated ___ Widowed ___ Common Law ___ Single
Child lives with: Parents: ____ Father: ______ Mother: ______ Legal Guardian: ________ Other: ________
Family Situations/Info that Colwood Preschool should be aware of: _______________________________________________
__________________________________________________________________________________________________________
Has a court order been made concerning the care or custody of the child? Yes ____ No ____ If yes, than please attach a copy
How did you hear of our school? _________________ Do you attend church? ____ No ____ Yes (name of church)____________
Siblings:
Name
Name
Name
Name
______________________
______________________
______________________
______________________
Gender:
Gender:
Gender:
Gender:
______
______
______
______
Age:
Age:
Age:
Age:
_________
_________
_________
_________
Activities and special interests of child: _______________________________________________________________________
Emergency Person/Contact: Name: _______________________ Home Phone:________________
Cell/Work Phone: __________________ Relationship to child: ___________
If appropriate, English speaking contact: Name: ______________________Phone: _____________
General Health: please complete in full!
Family Physician:
___________________________________________ Phone: ________________
Family Dentist:
___________________________________________ Phone: _________________
Personal Health (Care Card) Number: _______________________________________
Energy Level:
___High ____ Low ____ Average
Is your child toilet trained?
___ Yes
Has your child received all immunizations?
___ No
___ Yes
___ No
A copy of childs immunizations or letter indicating that you have chosen not to immunize MUST accompany registration
Has your child had or do they require speech therapy?
Are there any indications of vision or hearing problems?
___ Yes
___ Yes
___ No
___ No
Does the child have any medical problem of which we should be aware (heart condition, diabetes, asthma, severe allergies, special
diet? If yes, please provide details: _____________________________________________________________________________
In cases of asthma or epilepsy, etc. please give date of last incident: ______________________________________
Is the child currently taking any medication on a regular basis Yes ____ No ____
If yes, please provide name(s) of medication ____________________________________________________________________
Does the child have a history of previous medical concerns or surgery Yes ____ No _____
If YES please provide details ___________________________________________________________________________________
Is your child currently being seen by any professionals Yes: ____ No: ____ If yes, please provide details: ______________________
If you have indicated that your child has a major medical condition which may possible result in a medical emergency while at school,
you are required to complete a more detailed form (Medical Alert Information and Care Plan). This info will enable us to plan for &
better assist the child should a medical emergency occur. This is required by licensing.
Social and Emotional Development
Child’s previous experience in a group: _______________________
How does your child prefer to play? alone ___ with playmates ____ siblings ____ with adults____
Does your child have any specific fears? ______________________________________________
How does your child respond when separated from you?_________________________________
Has the child ever experienced any social and/or learning difficulties Yes ___ No___ If yes, please provide details ________________
__________________________________________________________________________________________________________
Guidance and Behaviour:
How would you best describe your child is managed: _______ easily ______ with difficultly (please be specific) _________________
_________________________________________________________________________________________________________
Do you have concerns about your child’s present behavior? If yes, please specify ___________________________________
___________________________________________________________________________________________________________
What do you expect your child to gain from this experience?_______________________________
REGISTRATION FEES: $25.00 or $30.00 per family (2 or more children) This fee is non-refundable.
First Months fee payable by cash or cheque only. This secures your child’s registration and will be
processed unless we have received written notice by June 30th.
MONTHLY TUTION:
We require credit card or a void cheque for autowithdrawl, post dated cheques.
WITHDRAWAL NOTICE: One month’s written notice, or one month’s fee (in lieu of notice) is required if the child withdraws during the
school year.
WITHDRAWAL DATE: _________________________
** If your child is withdrawn after February 28th, June fees will be forfeited **
I/We have read the above statement; Parent Handbook & payment policy & I/We are in full agreement with them. I/We
understand that monthly fees guarantee my child’s space in the preschool; therefore no refunds will be given for times missed.
Parent(s) Signature: _______________________________________________________________ Date: ____________________