“WELCOME”
TO THE MEMORY LANE FAMILY PLACE PRESCHOOL
We are taking this opportunity to provide you with your initial registration package for the
2014/2015 preschool year.
We ask you to please complete these forms and return them to us as soon as possible. You can
drop them off to the centre or send via Canada Post. Forms can also be downloaded from our
web site and emailed to us.
Attached also is the Program Philosophy, Daily Routine and Preschool Policies for your reading.
An information meeting will be held on mid-May at the Memory Lane Family Place (22 Memory
Lane). We will advise you of the date. We will talk more about the program and dates for your
child to come to his/her orientation the first week of September. This meeting and the
children’s orientation will allow you and your child to meet staff and become familiar with the
centre and in particular the preschool environment. Your comfort is our utmost concern.
Preschool payments are made a month in advance, which means your first payment will be due by
August 15th. This will be your September payment. Your final payment will be made by May 15th
for the month of June. A deposit of $25.00 is required, which will hold your space. This is due
when the above forms are returned or you can bring to the May meeting. This is non-refundable
for registration purposes but will be deducted from your final payment. Preschool fees for the
2014-2015 year are $70.00 monthly (reduced rates may be available to families, who are
registering more than one child).
The centre has an open-door policy. Please feel free to contact us, if you have any questions,
comments or concerns. Your feedback is important!
We look forward to meeting with you at the parent information meeting.
“We hope you and your child enjoy your experience in the
Memory Lane Family Place Preschool Program.”
MEMORY LANE FAMILY PLACE PRESCHOOL
INITIAL INTAKE FORM
1. Parent(s)/Guardian: _________________________________________________
2. Civic/Mailing Address: _______________________________________________
Postal Code: ______________
3. Email Address: ____________________________________________________
4. Phone Number: (H) ___________ (C) _____________ (W) ________________
5. Child’s Full Name: __________________________________________________
6. Date of birth: ____________ Language(s) spoke at home: __________________
7. Height: _________________ Weight: _______________
8. Day/Time preferred: Mon/Wed a.m. ________ Tues/Thurs a.m. ________
9. Special Issues – i.e. Health/Medical/Behavior/Diet
____________________________________________________________________
____________________________________________________________________
________________________________________________________
10. What other programs is your child attending (i.e. playgroups, preschool, etc.)
____________________________________________________________________
____________________________________________________________________
________________________________________________________
11. Is there anything else you would like to tell us about your child and/or your family?
____________________________________________________________________
____________________________________________________________________
________________________________________________________
12. What is the reason or reasons you would like to have your child in our preschool program?
____________________________________________________________________
____________________________________________________________________
________________________________________________________
Form #1 – 4/13
MEMORY LANE FAMILY PLACE PRESCHOOL
GENERAL INFORMATION
Child’s Name_______________________________________________
Date of Birth: ______________________________________________
Parent or Guardian Name (s): ___________________________________
These questions are being answered by: ___________________________
1.
Is your child an only child?
_______________________________________________________________
2.
Has your child attended Nursery School or Day Care?
_______________________________________________________________
3.
Does he/she have an opportunity to play with other children on a daily basis?
_______________________________________________________________
4.
How does your child get along with other children?
_______________________________________________________________
5.
How does he/she feel about starting preschool?
______________________________________________________________
6.
How does he/she feel about starting school?
_______________________________________________________________
7.
Does your child show an interest in books?
_______________________________________________________________
8.
Does he/she enjoy listening to stories and being read to?
_______________________________________________________________
9.
What are his/her favorite stories?
_______________________________________________________________
10. What kind of activities does your child enjoy doing alone?
_______________________________________________________________
11. Is your child able to dress him/herself?
_______________________________________________________________
12. Is he/she able to:

Tie his/her sneakers: _______

Zip up his/her own jacket: _______

Fasten snaps on jeans, etc.: _______

Button his/her jacket etc.: _______
13. Does your child know:

His/her full name: _______

Name of parent (other than Mom or Dad): _______

His/her address: _______

His/her phone number: _______
14. What, if any, group activities has your child been involved in?
___________________________________________________________________
___________________________________________________________________
_______________________________________________________
15. If you could use one or two words (other than bright and adorable) to describe your son or
daughter, how would you describe him/her?
___________________________________________________________________
___________________________________________________________
Form #2 – 02/12
MEMORY LANE FAMILY PLACE PRESHOOL
QUICK REFERENCE
Name: ________________________
Date of Birth: ___________________________
Start Date: ____________________
End Date: ______________________________
Weekly Attendance: ________________________________________________________
Address: ________________________________________________________________
Postal Code: _____________________
Home #:_______________________________
Child’s Health Card Number: __________________________________________________
Allergies: _________________________
Medications: __________________________
_________________________
__________________________
Parent daytime contact number: ___________________________________
Caregiver contact number: _______________________________________
Emergency contact person: ________________________________________
Telephone: ___________________ Relationship to child:_________________
Environmental Issues/Sensitivities: _____________________________________________
_______________________________________________________________________
Habits: __________________________________________________________________
_______________________________________________________________________
Likes: ___________________________________________________________________
_______________________________________________________________________
Dislikes: _________________________________________________________________
_______________________________________________________________________
*I give permission for my child ___________________________ to be picked up by:
Name
1. _________________________
2. _________________________
3. _________________________
Phone Number
_____________________
_____________________
_____________________
If anyone else is to ever pick up my child, I will notify the staff in advance. The staff has the
right to ask for identification, if the person is unknown to them.
*I am willing to permit my child _______________________to go on outside expeditions with
appropriate supervision.
*I give permission for my child to receive medical attention, and to be taken to the hospital
in case of emergency, if I cannot be contacted.
*I give permission for my child’s picture to be taken.
(Note – Children’s photos are not put on internet – used internally only.)
Parent/guardian signature: ________________________ Date: ____________________
Form #3 – 4/14
Memory Lane Family Place Preschool
Child’s Health Questionnaire
To be completed by the parent(s)
Name of Child: ____________________ Date Of Birth: __________________
Health Card #: __________________________ Expiry Date: ______________
Parent(s) /Guardian Name:__________________________________________
Telephone: (H) ________________ (W)________________ (C)_____________
Start Date:____________________
End Date:________________________
IN CASE OF EMERGENCY:
Adult to contact if you cannot be reached:
1. Name: _____________________________ Relationship: ______________
Telephone (home) _____________________ (work) ___________________
2. Name: _____________________________ Relationship: ______________
Telephone (home) _____________________ (work) ___________________
Doctor and/or clinic:
Name: _________________________________________________________
Address: _______________________________________________________
Telephone: ________________________
st
1
IMMUNIZATION RECORD – Give Dates D/M/Y
2nd
3rd
4th
5th
DPTP
HIB
MMR
TDP
IB
Other
Dentist and/or clinic:
Name: _________________________________________________________
Address: _______________________________________________________
Telephone: _________________________
BACKGROUND INFORMATION:
Please list other children in the household. First name (last name only if different)
1. ________________________ Age ____
2. ________________________ Age ____
3. ________________________ Age ____
4. ________________________ Age ____
Language spoken at home ________________________________________________
Has your child been in a child care arrangement before? _______________
If your child has been cared for by family members or others (e.g. a neighbor), please describe
the child’s experience.
_______________________________________________________________________
_______________________________________________________________________
If your child has had group play experience, please describe how often your child attended, how
long were your child’s experience.
_______________________________________________________________________
_______________________________________________________________________
HEALTH AND DEVELOPMENT HISTORY:
Describe any difficulties or serious illnesses at birth, if any:
_______________________________________________________________________
Describe your child’s general health (e.g. recurrent colds, ear infections, stomach aches, etc.):
_______________________________________________________________________
_______________________________________________________________________
Are there presently any serious medical problems?
_______________________________________________________________________
_______________________________________________________________________
If your child is taking any medication, what medication and what is it for?
_______________________________________________________________________
_______________________________________________________________________
Has your child been to a dentist? ______________________________________________
Does your child have any dental problems: ________________________________________
Describe how your child communicates: __________________________________________
How would you describe your child’s emotional, physical and social growth and development to
this point?
_______________________________________________________________________
_______________________________________________________________________
______________________________________________________________________
Describe your child’s diet (including types of food and fluid)
Fluids/Beverages: ______________________________________________
Solids:
______________________________________________
Dislikes:
______________________________________________
Does your child have any allergies to food? ______________________________
If your child has food allergies, please list:
_______________________________________________________________________
_______________________________________________________________________
Does your child have any allergies to medication or contact allergies? __________
If yes, please describe and list:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Is the allergy severe enough to require medical and/or emergency treatment? ____
If yes, describe and detail any procedures required.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Has your child eaten peanut butter at home? Yes ___ No ___
Any reaction? ____________________
If yes, please describe: _____________________________________________________
(Please note – the Memory Lane Family Place is not peanut-free.)
Diet restrictions (cultural, religious):
_______________________________________________________________________
_______________________________________________________________________
Describe any concerns you have about your child’s diet and/or eating habits.
_______________________________________________________________________
_______________________________________________________________________
Describe your child’s sleeping habits and routine.
_______________________________________________________________________
_______________________________________________________________________
Is your child able to take care of his/her bathroom needs?
_______________________________________________________________________
Parent’s Signature ___________________________________
Form #4 - 02/14
Date ________________
BEHAVIOR PATTERNS and HABITS:
Describe your child’s behavior and habits (e.g. temperament, energy level):
_______________________________________________________________________
_______________________________________________________________
Describe an ordinary day in your child’s life, from getting up in the morning to going to bed,
including times for naps, meals and play, interests, activities, etc.
Morning: _________________________________________________________________
___________________________________________________________________
Afternoon: _______________________________________________________________
___________________________________________________________________
Evening: _________________________________________________________________
___________________________________________________________________
Describe your child’s particular attachments (e.g. toy, blanket, pets) and any particular habits
(e.g. thumb-sucking, rocking):
_______________________________________________________________________
_______________________________________________________________
Describe any particular fears your child has shown (e.g. to animals, loud noises and strangers):
_______________________________________________________________________
_______________________________________________________________
Describe how your child reacts to stressful situations/separation (e.g. cries, withdraws, has
tantrums, yells, swears, hits):
_______________________________________________________________________
_______________________________________________________________
How does your child react to new situations?
_______________________________________________________________________
_______________________________________________________________
We would appreciate your views on guiding your child’s behavior and setting limits:
_______________________________________________________________________
_______________________________________________________________
Is there anything else you would like to tell us about your child to help us provide the best
possible experience for him/her?
_______________________________________________________________________
_______________________________________________________________________
___________________________________________________________
Parent’s signature: _________________________
Form # 5 - 4/13
Date: _________________
MEMORY LANE FAMILY PLACE
PRESCHOOL POLICIES
Due to the need for program planning and set up, parents are asked to arrive no earlier than
five minutes prior to start time.
1. ATTENDANCE – Every attempt is made to wait for all children to arrive before starting
with activities. We ask that you please call the centre (846-6363), if you will not be
attending the program or if you are going to be late.
2. CLOTHING – Children attending the Memory Lane Family Place Preschool should dress for
messy activities. Good clothing is discouraged. This allows for freedom in play for children
and reduces the fear of adults that clothes will be soiled or probably ruined. When bringing
an extra change of clothing for your child, we ask that all items be marked and kept in a bag
with your child’s name on it.
3. CHILDREN’S CRAFTS – Children’s crafts are to be taken home daily, because of limited
space. We know you will display them with pride in your own home.
4. FACILITY

Fire and safety policies and procedures must be adhered to. They are posted on the
bulletin board in the preschool. Please familiarize yourself with them. A copy of the
evacuation plan is also attached to the board.

Daily attendance records are kept for both statistical purposes and fire requirements.

A fully stocked First Aid Kit is kept in the Preschool at all times.

Emergency numbers are posted in the preschool unit.

Hot beverages (i.e. coffee, tea) are not permitted in the Preschool or anywhere around the
children for safety reasons.

Staff will not be responsible for any personal belongings being misplaced at the Memory
Lane Family Place Preschool. Bringing toys from home is discouraged; also toys being taken
home from the centre is not permitted.

Diaper bags/purses must be kept on a counter, off the floor. This is necessary so that
children will not get into the bags. We cannot be responsible for the loss of purses, during
anytime you may be on site.
There is an information bulletin board located in the Preschool. Staff will post upcoming
events or information they feel would be helpful for parents. Please keep yourself updated.
5. SNACK – A nutritious snack of juice or milk/water will be provided during each session.
Two servings of snack will be prepared for all children. The children will be served juice,
then offered water. Parents are to inform staff of any special diets or allergies. A list of
these children and their allergies will be posted in the food prep area. Parents will be
responsible to provide an alternate snack for children with allergies. These substitute
snacks must comply with the Nova Scotia Day Care Regulations, as stated below.
“When additional foods for special occasions are donated by an outside source, the
licensee must ensure that foods offered are part of the Eating Well with Canada’s Food
Guide and that a list of ingredients, name of the person who prepared the food and any
special instructions are clearly labeled. All off-site food services used by a child care
centre must be licensed as a food service facility by the department of Agriculture”.
*NOTE: We are not a peanut-free centre. Please inform staff if your child has a
peanut allergy.
Food Safety –

Child care program can only purchase or receive donations of food or beverages from an
establishment permitted by the Department of Agriculture.

Staff must create a relaxing and enjoyable meal environment as per regulation.

Regulated child care settings welcome mothers to breastfeed anywhere in the facility or
when requested, regulated child care setting provide a comfortable space for breastfeeding
mothers.

Staff is responsive to children’s cues around hunger and provides snacks outside of the
regular schedule.

Staff encourages children to respond to hunger and feelings of fullness and children are not
forced to finish food that has been served.
6. ILLNESS – We must prevent the spreading of illness; therefore, if a child is not feeling
well, we ask they remain home.
Any of the following would disqualify attendance for children:

Temperature of 101F (38.5C) or higher.

Vomited that morning or the night before.

Diarrhea.

Rash diagnosed as “contagious”, or any undiagnosed rash.

Conjunctivitis (pink eye), or any eye condition where the eyes are itchy, red, swollen or
oozing.

Anything that is contagious, i.e. impetigo, ringworm, pinworm, chicken pox, measles,
etc.

A cold with a fever, runny nose, sneezing or bad cough.

Head lice – treatment, (nix shampoo), must be completed and all nits gone from the
head.
*Please inform staff if your child or the children in your care have come in contact with a
contagious condition; we will inform other parents/guardians of the group so they can
observe their children.
7. MEDICATION – Parents are responsible for administering any medication their children
may require during their time at the Memory Lane Family Place Preschool. Please inform
staff if your child is using medication, and if your child has any medical condition that staff
may have to monitor, (i.e. Asthma).
8. HOLIDAYS – Preschool programs at the Memory Lane Family Place will not be offered on
statutory and some non-stat holidays and any other day when school may be cancelled, i.e.,
storm days. Following is a list of holidays, relative to the preschool year1.
2.
3.
4.
Thanksgiving Day
Remembrance Day
Christmas Day
Boxing Day
5.
6.
7.
8.
New Year’s Day
Good Friday
Easter Monday
Victoria Day
9. CONDUCT/CONFIDENTIALITY – The Memory Lane Family Place Preschool is thought of as
a model for everyone. Adult-like behavior, (especially as it relates to language) is expected.
The children are watching and listening. Complete professional behavior is expected at all
times from everyone. We especially ask parents to be mindful about discussing their
children in front of them.
Problem solving is always encouraged. If you are unhappy with anything at the Memory Lane
Family Place Preschool, you are asked to please direct your concerns to staff. Idle gossip is
unproductive and often harmful. Strict confidentially is expected.
*The centre has a ZERO tolerance policy with respect to any form of corporal punishment,
which includes slapping, shaking, yelling, pushing or humiliating another person.
Parents are asked to familiarize themselves with the centre’s Behavior Guidance Policy,
posted on the bulletin board.
10. EVALUATION – An integral part of the centre’s operation is ongoing evaluation. You may
be asked from time to time to participate in completing questionnaires, surveys or attending
focus groups. Your participation is always voluntary.
Your cooperation in following these policies would be greatly appreciated. They are designed to
make things easier for everyone.
Your input/feedback is always encouraged and valued. We are always open to change.
“We look forward to working with you and your children and welcome you!!”
Form #6 – 02/14
MEMORY LANE FAMILY PLACE PRESCHOOL
This will serve to confirm that I _____________________________ have
received a copy of the preschool polices. (Form #6)
Signed: __________________________________________________
Date: _______________________________
MEMORY LANE FAMILY PLACE PRESCHOOL
FINANCIAL POLICIES
Thank you for registering with the provincially-licensed Memory Lane Family Place Preschool.
We would like to welcome you and your child(ren). We are open to any
comments/ideas/suggestions you may have on the financial policies. Just let us know!
PAYMENTS – The monthly fee for the 2014/2015 preschool year is $70.00. Fees are collected
one month in advance. Your first payment is due by August 15th, which is your September
payment and your last payment would be made by May 15, 2015, for the month of June.
In the past we have been able to offer financial subsidies to families. Unfortunately, this is no
longer possible. Should we receive any community support to assist parents with their fees, we
will advise you.
Also, in the past, we were able to provide transportation to our families at a minimal cost.
Unfortunately, this service is no longer available.
METHOD OF PAYMENT - If paying by cheque, please make it payable to the Memory Lane
Family Place Preschool. Post-dated cheques are accepted, if this is easier for you. Should you
incur an NSF cheque, future payments will have to be made in cash or by money order. Payments
are made to the office and receipts will be made available. We ask that payments not be put in
children’s backpacks. Preschool staff do not check the children’s backpacks. We appreciate
your cooperation in this regard. 
HOLIDAYS – Please refer to item #8 in your preschool policies, which outline the days the
centre is closed. We are also closed on storm days, when schools are closed or when we feel the
roads are unsafe. When, and if, other times arise not listed in your policies, you will be notified
(example, Christmas break). Parents will pay for any and all holidays.
“We look forward to working with you and your children and welcome you!!”
Form #7 – 2/14
MEMORY LANE FAMILY PLACE
PRESCHOOL PHILOSOPHY
_______________________________________________________
Preschoolers do not learn in the same manner as older children and adults. Their intellectual
growth is connected to and depends upon their social, physical, and emotional development.
Much of what they learn derives from hands-on experience they get through play. This program
will provide a variety of activities and materials to encourage children to explore and discover.
Adults are an important part in the child’s journey through learning by providing the room to
play and centering the curriculum around the needs of the child. The adults can stimulate a
preschooler’s natural instinct to learn by providing a supportive environment and a wide variety
of developmentally appropriate activities.
The children will benefit from social interactions with others their age through opportunities
for developing social problem-solving techniques, such as negotiation and cooperation as well as a
chance to develop individuality and creativity by re-enacting events they have either
experienced or heard about such as shopping, moving, going to the doctor, etc.
Language development will be enhanced as both the adult and children introduce new vocabulary.
Children will be encouraged to communicate their feelings and express their ideas.
Through the activities and experiences provided, children will have the opportunity to work on
fine and large motor skills. By offering sensory and tactile activities, children can exercise
their hand-eye coordination skills.
The materials in the room will benefit the child’s intellectual development in the form of special
relations, problem solving with puzzles, and thinking about the past and future when building
with the materials provided. The children’s cognitive development will be stimulated when they
use classification to sort materials or serration to put things in order.
The children’s emotional development will be enriched through the exploration of the materials,
leading to a sense of accomplishment and strong self-esteem.
Staff will facilitate the child’s learning by being supportive and offering developmentally
appropriate experiences in which the children can engage.
This play-based philosophy enhances concept building and readiness for school and life.
We look forward to providing these opportunities for your family.
Memory Lane Family Place
Form #8 - 02/14
DAILY ROUTINE
_____________________________________________________
1. Table Top Activities
As children arrive, they will take part in individual tabletop activities (puzzles, play dough,
games, etc.). This allows a chance for grouping, socialization and connecting.
2. Circle Time
Children come together to share thoughts on their day and prepare for the rest of their
day at preschool.
3. Clean up and Snack
Children will be encouraged to participate in the process of meal preparation and serving, as
well as tidy up.
4. Free Activities
Learning centers are arranged for children to choose their own areas of play. Children may
be involved in exploration in the art areas, development of small motor, manipulation,
housekeeping and dramatic play.
5. Individual or Group Work
This is an opportunity for children to participate in hands-on activities which may include
arts/craft, activity sheets or clay creations.
6. Closing Circle
Children come together as a group to participate in a story and song to put a closing to
their day.
Form #9 – 02/14