REGISTRATION APPLICATION
Southdale Nursery School Inc.
P.O. Box 48091, Station Lakewood
Winnipeg, Manitoba, R2J 4A3
Date Received:_____________________
Phone: (204) 254-0589
Email: southdalenurseryinfo@shaw.ca
Applicant #: _______________________
Web Address: http://southdalenurseryschool.shawwebspace.ca/
________________________________________________________________________________________________
Preference:
AM (8:45 – 11:15 AM)
PM (12:30 – 3:00 PM)
No Preference
Child’s Name: ____________________________________________________________________
Male / Female
(Circle name your child prefers)
Home Address: __________________________________________________
Postal Code: ____________________
Home Phone: _____________________________ Date of Birth (Mmm-dd-yyyy): ______________________________
Email Address: _____________________________________________________________________________________
(Used for school correspondence ONLY)
MOTHER
Name: ____________________________________________________________________________________________
Home Address: ____________________________________________________________________________________
Home Phone: ______________________________________ Cell Phone: ______________________________________
Place of Employment: ___________________________________________ Phone: _____________________________
Employment Address: _______________________________________________________________________________
FATHER
Name: ____________________________________________________________________________________________
Home Address: ____________________________________________________________________________________
Home Phone: ______________________________________ Cell Phone: ______________________________________
Place of Employment: ___________________________________________ Phone: _____________________________
Employment Address: _______________________________________________________________________________
EMERGENCY INFORMATION
Child’s Physician: ___________________________________________________ Phone: _________________________
Manitoba Health # (6 digit): _________________________ PHIN # (9 digit): ___________________________________
ALLERGIES?
YES (If yes, please provide further details on the next page)
NO
Emergency Contact (Other than those listed above)
Home Phone: _________________________
Name: ________________________________________________________
Cell Phone: _______________________
________________________________________________________________________________________________
Page 1 of 10
REGISTRATION APPLICATION
Southdale Nursery School Inc.
P.O. Box 48091, Station Lakewood
Winnipeg, Manitoba, R2J 4A3
Date Received:_____________________
Phone: (204) 254-0589
Email: southdalenurseryinfo@shaw.ca
Applicant #: _______________________
Web Address: http://southdalenurseryschool.shawwebspace.ca/
________________________________________________________________________________________________
HEALTH INFORMATION
Immunizations up to date:
YES
NO
List all childhood diseases that your child has had: _______________________________________________________
__________________________________________________________________________________________________
Medical Conditions (IE: Asthma, Surgeries): _____________________________________________________________
__________________________________________________________________________________________________
Allergies (Describe all allergies and the severity of the reactions): ____________________________________________
__________________________________________________________________________________________________
Dietary Restrictions: ________________________________________________________________________________
__________________________________________________________________________________________________
Please comment on factors that may affect your child’s adjustment in this program, such as hand preference, speech
difficulties, friends or relatives in this program.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Siblings
Age
Attended Southdale
Nursery School (Y /N)
Year Attended
FIELD TRIP PERMISSION
I give permission for my child to attend all field trips and outings planned by the Southdale Nursery School during this
school year.
YES
NO
Parent’s Initials: ___________________
________________________________________________________________________________________________
Page 2 of 10
Southdale Nursery School Inc.
REGISTRATION APPLICATION
P.O. Box 48091, Station Lakewood
Winnipeg, Manitoba, R2J 4A3
Date Received:_____________________
Phone: (204) 254-0589
Email: southdalenurseryinfo@shaw.ca
Applicant #: _______________________
Web Address: http://southdalenurseryschool.shawwebspace.ca/
________________________________________________________________________________________________
RELEASE INFORMATION:
Child’s Name: ______________________________________________________
This information is required to assure the safety of your child when he or she leaves the nursery school.
1.
2.
3.
4.
Who will usually pick up your child? ______________________________________________________________
Any other Adult? _____________________________________________________________________________
Older Siblings? _______________________________________________________________________________
Is there anyone who your child should NOT be released to? __________________________________________
If yes, Why? _________________________________________________________________________________
Please provide written notification to the Nursery School if someone other than the above-mentioned persons will be
picking up your child.
Southdale Nursery School takes responsibility for your child after they are dropped off at school and signed in by the
parent / guardian each day. Once they are picked up and signed out by the parent / guardian, they are no longer the
responsibility of Southdale Nursery School.
We understand that it is our responsibility to notify Southdale Nursery School of any changes to any of the facts recorded
in this application. Without accurate information, the School is unable to act in the best interest of our child.
FEES:
We agree to pay the annual registration fee of $1,040.00 as follows:
Non-refundable deposit due at time of registration:
Monthly Paymets
Remaining fees payable in post-dated cheques.
(9 cheques in the amount of $100.00 each. All cheques dated
for the 1st of each month – September 1, October 1, November
1, December 1, January 1, February 1, March 1, April 1, May 1)
$140.00
- OR -
Payment In Full
Remaining fees paid in full.
(Cash or cheque dated September 1)
$100.00 X 9 cheques
$900.00
Total (with deposit)
$1,040.00
*Please note that there will be a $20.00 service charge for each N.S.F. cheque.
________________________________________________________
Parent / Guardian Signature
________________________________________________________
Board Member Signature
$900.00
$1,040.00
__________________________
Date
__________________________
Date
________________________________________________________________________________________________
Page 3 of 10
Southdale Nursery School Inc.
REGISTRATION APPLICATION
P.O. Box 48091, Station Lakewood
Winnipeg, Manitoba, R2J 4A3
Date Received:_____________________
Phone: (204) 254-0589
Email: southdalenurseryinfo@shaw.ca
Applicant #: _______________________
Web Address: http://southdalenurseryschool.shawwebspace.ca/
________________________________________________________________________________________________
PERSONAL INFORMATION CONSENT FORM
(Please read and complete the following 3 pages and sign accordingly.)
SOUTHDALE NURSERY SCHOOL INC. is herein referred to as the “FACILITY”
This Form applies to the child named below, who will be attending the Facility and who is herein called the “CHILD”.
Child’s name: _______________________________________________
By signing below, I hereby consent to the Facility:
a) Collecting:
i) All of the personal information included in any Application/Enrollment/Registration Form (a “Registration
Form”) that I may complete and give to the Facility about the Child, me and any other individual whose
personal information is included in the Registration Form, and
ii) Any additional personal information regarding the Child, me and/or any such other individual that the
Facility may reasonably require and collect by way of additional documents and/or
b) Collecting all of the personal information in any Subsidy Application/Financial Assistance Form (a “Subsidy
Form”) that I may complete and/or give to the Facility about the Child, me, and
c) Collecting any additional personal information included in any other document that I may complete and/or give
to the Facility about the Child, me and any other individual whose personal information is included in
i) A Child Information Record,
ii) A Family Information Record,
iii) A Pre-Authorized Payments Form,
iv) A Custody Arrangements Agreement,
v) A Medication Administration/Authorization Form,
vi) An Emergency Medical Attention Form,
vii) A Daily Care Record,
viii) A Food Allergy Action Plan, and
ix) Any Special Needs Form
(Collectively the “Other Forms”, and with the Registration Form, and Subsidy Form and all Other Forms
being herein collectively called the “Forms”);
d) Collecting on an on-going basis, additional personal information about the Child, me and any other individual
who is referred to in any Form (a “Named Individual”), as reasonably required at any time by the Facility to
provide for:
i) The physical, emotional, social and intellectual well being and safety of the Child, or
ii) The general administration and operation of the Facility (which includes record keeping, debt collection and
fund-raising activities);
________________________________________________________________________________________________
Page 4 of 10
Southdale Nursery School Inc.
REGISTRATION APPLICATION
P.O. Box 48091, Station Lakewood
Winnipeg, Manitoba, R2J 4A3
Date Received:_____________________
Phone: (204) 254-0589
Email: southdalenurseryinfo@shaw.ca
Applicant #: _______________________
Web Address: http://southdalenurseryschool.shawwebspace.ca/
________________________________________________________________________________________________
e) Using all of the personal information included in any Form and all other personal information previously or
subsequently collected by the Facility regarding the Child, me and/or any other Named Individual, as reasonably
required by the Facility to provide for:
i) The physical, emotional, social, and intellectual well being and safety of the Child, or
ii) The general administration and operation of the of the Facility (which includes record keeping, debt
collection and fund-raising activities);
f)
Disclosing on a “need to know”, and where applicable, on a confidential basis, any personal information about
the Child, me and/or any Named Individual:
i) To the Facility’s employees, independent contractors (ie. People who regularly work at the Facility but who
are not paid as employees), directors, therapists, volunteers (which may include parents and/or legal
guardians of other children attending the Facility), work experience students and educational or regulatory
observers; or
ii) To any third party who requires such information in order to:
A) Provide (or assist the Facility in providing) for the physical, emotional, social and/or intellectual well
being and/or safety of the Child; or
B) Assist the Facility in its general administration and/or operations (which includes record keeping, debt
collection and fund-raising activities); or
C) Assist the Facility in providing products and/or service to the Child and/or to me; or
iii) To a public authority or an agent of a public authority if, in the Facility’s reasonable judgment, it appears
that there is imminent danger to life or property which could be avoided or minimized by the disclosure of
that information; or
iv) To any third party who requires such information and who is part of the Facility’s organizational structure; or
v) To any third party with whom the Facility is negotiating for the purpose of that third party taking over some
or all of the Facility’s services and/or activities; or
vi) To representatives of other licensed child care facilities if I have not properly satisfied my debts to the
Facility;
g) Disclosing the name of the Child in any class list produced by the Facility for the Child’s class(es) at the Facility
and made available to the families of children in each class/time slot;
h) Disclosing the Child’s first name and the first initial of the Child’s surname on a name tag (whenever other
children in the Facility are given name tags) on the Child’s clothing and on various items throughout the Facility –
for example, a sign-in/sign-out sheet, an allergy sheet, a cubical, a locker and a notebook or scrapbook;
i)
Disclosing (and celebrating) the Child’s birthday(s);
CHECK THIS BOX IF YOU DO NOT WANT YOUR CHILD’S BIRTHDAY(S) DISCLOSED OR CELEBRATED.
________________________________________________________________________________________________
Page 5 of 10
Southdale Nursery School Inc.
REGISTRATION APPLICATION
P.O. Box 48091, Station Lakewood
Winnipeg, Manitoba, R2J 4A3
Date Received:_____________________
Phone: (204) 254-0589
Email: southdalenurseryinfo@shaw.ca
Applicant #: _______________________
Web Address: http://southdalenurseryschool.shawwebspace.ca/
________________________________________________________________________________________________
j)
Allowing appropriate photographs and/or videos of the Child to be taken by therapists, by work experience
students and by educational or regulatory observers while they are at the facility;
k) Taking appropriate photographs and/or videos (or allowing appropriate photographs and/or videos to be taken)
of the Child and using any such photograph and/or video in the Facility’s program activities, archives and/or
promotional materials; and
CHECK THIS BOX IF YOU DO NOT WANT YOUR CHILD’S PICTURE TO BE TAKEN FOR THIS PURPOSE.
l)
Allowing appropriate photographs and/or videos of the Child to be taken by;
i) Employees of the Facility for their personal records; or
CHECK THIS BOX IF YOU DO NOT WANT YOUR CHILD’S PICTURE TO BE TAKEN FOR THIS PURPOSE.
ii) Representatives of the media or of any granting organization, for use in media coverage, article or
promotional materials; or
CHECK THIS BOX IF YOU DO NOT WANT YOUR CHILD’S PICTURE TO BE TAKEN FOR THIS PURPOSE.
iii) Parents of other children at the Facility at special events or field trips organized by the Facility.
CHECK THIS BOX IF YOU DO NOT WANT YOUR CHILD’S PICTURE TO BE TAKEN FOR THIS PURPOSE.
Also, by signing below, I acknowledge that the Facility may collect and disclose personal information regarding the Child,
me and/or any Named Individual, without consent of the Child, me or Named Individual, where:
a) The Facility is required by law to make any such disclosure (for example, to the Manitoba Day Care Program in
order to comply with licensing conditions); or
b) A staff member of the Facility suspects abuse, neglect or endangerment involving the Child (for example, to the
Director of Child Welfare, Manitoba Child and Family Services or to a law enforcement agency).
__________________________________________
Signature of Parent/Legal Guardian
__________________________________________
Name of Parent/Legal Guardian (please print)
__________________________________________
Date
_________________________________________
Signature of Parent/Legal Guardian
_________________________________________
Name of Parent/Legal Guardian (please print)
__________________________________________
Date
________________________________________________________________________________________________
Page 6 of 10
Southdale Nursery School Inc.
REGISTRATION APPLICATION
P.O. Box 48091, Station Lakewood
Winnipeg, Manitoba, R2J 4A3
Date Received:_____________________
Phone: (204) 254-0589
Email: southdalenurseryinfo@shaw.ca
Applicant #: _______________________
Web Address: http://southdalenurseryschool.shawwebspace.ca/
________________________________________________________________________________________________
Policy Handbook
Please review the Policy Handbook. It is available online at www.southdalenurseryschool@shawwebspace.ca. If you
would like a hard copy, please ask one of the staff or board members.
I, __________________________________________ , have read and understand the Policy Handbook.
Name of Parent/Legal Guardian (please print)
__________________________________________
Signature of Parent/Legal Guardian
__________________________________________
Date
________________________________________________________________________________________________
Page 7 of 10
Southdale Nursery School Inc.
REGISTRATION APPLICATION
P.O. Box 48091, Station Lakewood
Winnipeg, Manitoba, R2J 4A3
Date Received:_____________________
Phone: (204) 254-0589
Email: southdalenurseryinfo@shaw.ca
Applicant #: _______________________
Web Address: http://southdalenurseryschool.shawwebspace.ca/
________________________________________________________________________________________________
Volunteers needed for Board of Director Positions!
On behalf of the outgoing Southdale Nursery School Board of Directors, we thank you for registering your child
for the 2012-2013 year at Southdale Nursery School. The upcoming school year should be an exciting one! The
Southdale Nursery School Board of Directors plays an essential role in the functioning of the Southdale Nursery
School. The Board of Directors is comprised of parent volunteers of children enrolled in the program.
If you are interested in volunteering for one of the open board positions, please complete and submit this form
with your registration application.
YES!
I would like to be involved in my child’s nursery school education and am interested in the following
board position:
PRESIDENT
VICE PRESIDENT
SECRETARY
(MUST have access to a computer and be comfortable with
basic word processing and spread sheets)
TREASURER
MORNING PARENT ADVISOR
AFTERNOON PARENT ADVISOR
Parent’s Name: __________________________________________ Phone Number: ____________________________
Please see attached sheets for job descriptions.
________________________________________________________________________________________________
Page 8 of 10
Southdale Nursery School Inc.
REGISTRATION APPLICATION
P.O. Box 48091, Station Lakewood
Winnipeg, Manitoba, R2J 4A3
Date Received:_____________________
Phone: (204) 254-0589
Email: southdalenurseryinfo@shaw.ca
Applicant #: _______________________
Web Address: http://southdalenurseryschool.shawwebspace.ca/
________________________________________________________________________________________________
Southdale Nursery School – Board of Directors Job Descriptions.
Responsibilities of the President
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Study By-Laws
Review parliamentary procedures
Study Licensing manual for day care centers
Study the policies and operations of Southdale Nursery School Inc.
Review predecessor’s files
Familiarize yourself with the budget, the audited financial statements and any other financial reports
Chair each meeting of the Board of Directors and at general meetings (executive meetings are arranged at an Executive member’s home
or Teacher’s home, or any other agreed upon venue)
Exercise general supervision over all Board activities
Prepare an agenda for each meeting of the Board and for each general meeting
Co-ordinate the total Board effort
Responsible for orientation of new members. Explaining their responsibility for service on the Board.
Arranging general meetings of the Board.
Exercise general supervision over any fundraising activities
Signing of all cheques for the Nursery School along with Treasurer. (Other signing authority will be Vice President in case of absence of
one of the executive)
Sending out correspondence in early February, advertising for enrollment in the Nursery School for next term. (May be necessary to
advertise in August as well to fill any remaining vacancies)
Make speech at meeting on registration night to fill Executive Member spots and to introduce staff members as well as chairing the
meeting prior to registration
Make sure that each member of the Executive is performing their duties
Applying to LRSD for permission for use of the rooms for registration meeting. (Please ask for forms from front office)
Yearly renewal of lease space for Southdale Nursery School
Send out letters to Bank and LRSD with Board Member changes at the end of the school year
Liaise with parents during summer months
Responsibilities of the Vice President
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Act as the President’s principal assistant
Signing of cheques for the nursery school as required
Attend board meetings
Assist at registration night
Initiate, oversee and actively participate with all fundraising
Assist teachers where required to prepare materials or arrange parental / volunteer help
Assist with any other functions requested by the President
Compile / order / separate / handout and maintain accounting of and paying bills for Scholastic Books
Discuss and make joint decisions with the Board Members
Decide with President, issues needing to be discussed at meetings
Gain knowledge needed to act in the President’s place if necessary by reviewing records of predecessor, studying the duties and
responsibilities of all board positions and attend and provide input in decision making at the board meeting
Be aware of all by-laws
Study the policies and goals of the nursery school
Familiarize yourself with the budget of Southdale Nursery School, the audited financial statements and other financial reports
Responsibilities of the AM and PM Advisors
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The parent advisors will attend Board meetings and will liaise between parents and board members
The parent advisors will assist with fundraising activities
The parent advisors will assist with board activities and responsibilities as needed (i.e. preparation of fall registration packages, web
maintenance, etc)
________________________________________________________________________________________________
Page 9 of 10
Southdale Nursery School Inc.
REGISTRATION APPLICATION
P.O. Box 48091, Station Lakewood
Winnipeg, Manitoba, R2J 4A3
Date Received:_____________________
Phone: (204) 254-0589
Email: southdalenurseryinfo@shaw.ca
Applicant #: _______________________
Web Address: http://southdalenurseryschool.shawwebspace.ca/
________________________________________________________________________________________________
Responsibilities of the Treasurer
ACCESS TO A COMPUTER / PRINTER, QUICK BOOKS, AND INTERNET IS A MUST FOR THIS POSITION.
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Study by-laws
Study licensing manual for day cares
Study the policies and operations of Southdale Nursery School Inc.
Review predecessor’s files and maintain six (6) years worth of financial records at their home
Make arrangements with the bank to transfer the account to your custody and to have the signatures changed
Study the budget of Southdale Nursery School, the audited financial statement and any other financial reports
To prepare and mail Corporations Act Form and Fee (Corporations Branch, 405 Broadway)
Receive funds and issue receipts as necessary
Ensure accurate records of all receipts and disbursements are maintained
Ensure all bills, vouchers, receipts, and other supporting evidence is available for use by the auditor
Ensure bank records are reconciled
Prepare quarterly Treasurer’s Report for Executive Board meetings
Assist the teachers in the preparation of the annual budget
Ensure financial statements are prepared at year-end for Revenue Canada
To recommend direction on behalf of Southdale Nursery School, i.e. recommendation to fundraise
Apply for necessary grants
Communicate with payroll as required
Calculation of benefits deduction amount each June
Prepare/calculate/submit Contribution Listing Form, for Registered Pension Plan on a bi-weekly basis
Prepare/calculate/submit Pension Plan Reimbursement Applications on a Quarterly basis
Annual renewal of all insurances (Directors and Officers Liability Insurance, WCB, MB Child Care Association, Office of Fire Commissioner
Inspection)
Pick up nursery school mail and annual renewal of post office box rental
Prepare tax reciepts
Responsibilities of the Secretary
ACCESS TO A COMPUTER AND BASIC KNOWLEDGE OF WORD PROCESSING / SPREADSHEETS IS A MUST FOR THIS POSITION.
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Attend board meetings and keep accurate records on all board meeting minutes. Distribute copies of minutes to Board.
Assist at registration night
Assist with and actively participate in any fundraising
Assist teachers where required to prepare materials or arrange parental / volunteer help
With assistance from other capable Board Members, maintain the Southdale Nursery School Web Page
Assist with the creation of newsletters, calendars and snack assignments for the nursery school
Post all newsletters and calendars to the website in both Microsoft Word and Adobe .PDF format
Email all families, board members and teachers with the links to the updated posts to newsletters and calendars on the website
Discuss and make joint decisions with Board members
Be aware of all by-laws, and Study policies and goals of the nursery school
Study the licensing manual for Day Care Centers, including regulation governing licensing and funding of Southdale Nursery
Review previous years’ board meeting minutes
Attend to the correspondence of the nursery school
Keep a roster of contact information of board members
Prepare and update a class list and ensure Board Members and director have current copies at all times
With the President, prepare teachers’ contracts as required
Prepare registration package in February for March registration (assisted by AM and PM parent Advisors)
Prepare fall information package to be sent to parents in August
Prepare teacher evaluation forms for distribution to the parents by the end of April
Send out confirmation letters to parents after spring registration night
Keep 5 years worth of information in the Secretary binder and/or on digital storage media (CD, memory stick or similar)
Secretary is the custodian of the seal of the Organization.
________________________________________________________________________________________________
Page 10 of 10