Membership Portal

C'imo'ca Childcare Centre Registration Form

Daycare Registration Form

Child Information

Radio Field

Preschool – Monday to Friday, 8:45 AM to 11:15 AM; child must be 4 before January 1st

Nursery – Monday to Friday, 8:45 AM to 11:15 AM; child must be 36 months by January 1st

Infant Toddler – Monday to Friday, 7:30 AM to 4:30 PM; age 0 to 30 months

Daycare Group Care – Monday to Friday, 7:30 AM to 4:30 PM; age 30 months to 6 years

Date of Birth

Gender

Male

Female

Last Name

Given Name

Also Known As

Child's Home Address

Street Address

City

Province

Postal Code

Band Affiliation

Band Number

Parent/Guardian Information

Parent/Guardian 1

Last Name

Given Name

Relationship

Mother

Father

Guardian

Band Affiliation

Band Number

Address

Street Address

City

Province

Postal Code

Home Phone Number

Cell Phone Number

Work/School Phone Number

E-mail Address

Parent/Guardian 2

Last Name

Given Name

Relation

Mother

Father

Guardian

Band Affiliation

Band Number

Address

Street Address

City

Province

Postal Code

Home Phone Number

Cell Phone Number

Work/School Phone Number

E-Mail Address

Are there any custody arrangements?

Please attach a copy of any court documents that may exist

Choose File

Emergency Contact List

Last Name

Surname

Cell Phone

Home Phone

Relationship to child

Last Name

Surname

Cell Phone

Home Phone

Relationship to child

Last Name

Surname

Cell Phone

Home Phone

Relationship to child

Health Information:

*Your child will not be permitted to start the program until a PHN Number is submitted.*

Personal Health Card Number (Care Card)

Family Doctor

Phone/Mobile

Family Denstist

Phone/Mobile

Has your child had a:

Results

Does your child have:

Allergies

Yes

No

Special Diet

Yes

No

Specify

Medical Concerns

Yes

No

Medications Taken

Yes

No

Specify

Are your child’s immunizations up to date?

Yes

No

Consents

By initialing the following, I understand that I am giving permission for the following to occur:

(Emergency) I hereby give my consent for the staff of c’imo’ca childcare centre to seek medical attention or call an ambulance for my child, if necessary in the event that I am unable to be contacted. I will be responsible for any charges that may result if such an emergency shall arise.

Agree

Disagree

Caregiver’s initial

(Information Release) This registration information is made available to the Community Care Facilities Licensing Office, The Environmental Health Officer, the Fire Chief and the Community Health Nurse. By signing and initially this form you are giving consent to having your child take part in the drop in visits by these health and safety practitioners.

Agree

Disagree

Caregiver’s initial

(Photographs, Video/Audio Recording) I give the staff of c’imo’ca childcare centre permission to take photos, video and audio record my child and enjoyed by the staff, children and other families. I understand that my permission will be asked if my child’s documents will be used for any other reason. (E.g. local newspapers, Dootilh Articles, class assignments, or community display, etc.) These pictures may also be posted on c’imo’ca Head start facebook site.

Agree

Disagree

Caregiver’s initial

Community Field Trips I give permission for my child, to participate in community field trips and neighbourhood walks. I will be notified and a separate consent form will be signed for separate field trips that occur outside of our community of Kitamaat Village.

Agree

Disagree

Caregiver’s initial

Kitimat Child Development Centre Throughout the year, c’imo’ca childcare centre will have consultative visits from the Early Intervention Department of the Kitimat Child Development Centre. By signing this document I understand that I am giving permission for my child, to interact act with the professionals.

Agree

Disagree

Caregiver’s initial

Pick up authorization:

I authorize the following people to remove my child from c’imo’ca childcare centre (Your child will not released to anyone under the age of 16). I understand that if they are not on the list and prior arrangements (i.e. a phone call or note) have not been made with the staff, my child will not be released. I understand this policy
is for the safety of my child.

Caregiver’s initial

Name

Relationship to child

Address

Phone/Mobile

Email

Name

Relationship to child

Address

Phone/Mobile

Email

Name

Relationship to child

Address

Phone/Mobile

Email

Name

Relationship to child

Address

Phone/Mobile

Email

What care do you need

Full Time

Hour's

Part Time

Hour's

We use the Storypark App please provide the email addresses of adults who will need to be in contact with the daycare. You will receive support to download the app at your meeting.

Name

Email

Name

Email

Name

Email

I have completed the above information completely and correctly, and will notify c’imo’ca childcare centre staff immediately if there are any changes.

After the enrolment has been completed, you will be contacted by the Preschool to set up a time for an interview that will allow us to get to better know your child before entering the classroom. The children enrolled in the program will not be permitted into the program until this process has been completed.

Date / Time

Special instructions/notes.

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