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Gallery
Programs
Subsidy
Registration
Contact Us
Careers
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Gallery
Programs
Subsidy
Registration
Contact Us
Careers
Registration
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Registration
General Information
Child's Name
*
Date of Birth
Day
Month
Year
Address
Mother (Guardian)’s Name
Living with a child
Yes
No
(*If No, Address required)
Phone Number
(Work/Home)
Mobile
Address
Email
Father (Guardian)’s Name
Living with a child
Yes
No
(*If No, Address required)
Phone Number
(Work/Home)
Mobile
Address
Email
Emergency Contact
At least 1 contact should not be one of parents or guardians
Contact Person 1 Name
Phone Number
(Work/Home)
Mobile
Address
Relationship to Child
Contact Person 2 Name
Phone Number
(Work/Home)
Mobile
Address
Relationship to Child
Health Information
Child's Alberta Health Care Number
*
Child Immunization up to date
Yes
No
Doctor's Name
Phone Number
Clinic Address
Does your Child have any allergies?
Yes
No
Description for any allergies.
Does your child have any food restrictions or eating problems?
Yes
No
Description for any food restrictions or eating problems.
Is your child on regular medication (for a diagnosed medical condition)?
Yes
No
Description for on regular medication (for a diagnosed medical condition).
Does your child have a serious medical problem?
Yes
No
Description for a serious medical problem.
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