Corpus Christi Childcare Centre
Full Time
Junior Kindergarten (JK) Daycare
2360 Waverley St.Vancouver,BC V5P 4K5
Tel604-321-1117 Fax 604-321-1410
STUDENT APPLICATION
STUDENT INFORMATION
CHILD’S NAME: _____________________________________________________________________________________
FIRST NAME MIDDLE NAME LAST NAME (ALSO KNOWN AS)
BIRTHDATE: _______________ FEMALE ______ MALE________ BIRTH PLACE ____________________________
Y/M/D
ADDRESS:_
________________________________________________________________________________________
LANGUAGE SPOKE AT HOME:________________________HOME PHONE:________________________ H
PRIVOUHAS YOUR CHILD PREVIOUSLY ATTENDED DAYCARE?
YES______NO______COMMENTS: ___________________________________________________________________
RELIGIOUS INFORMATION
I
CHILD’S RELIGION:
______________:
_ PLACE OF BAPTISM______
______ DATE OF BAPTISM:
PARENT’SRELIGION: FATHER:_______________ MOTHER: __________________
PARISH WHERE NOW REGISTERED:__________________________________ ENVELOPE#:_________________
COMMENTS/INSTRUCTIONS TO HELP CARE FOR YOUR CHILD
TOILEING (SPECIAL WORDS: _________________________________________________________________________
REST (SPECIAL COMFORT– TOY/BLANKET):_______________________________________________________
EATING/MEALTIME (FOODLIKES/DISLIKES): ____________________________________________________________
FEARS: ___________________________________________________________________________________________
OTHER COMMENTS:__________________________________________________________________________
__
LEARNING CONCERNS
HAS YOUR CHILD BEEN ASSESSED OR DIAGNOSED WITH SPEECH AND LANGUAGE DISABLILITIES?
YES____NO_____ IF YES, PLEASE SPECIFY _____________________________________________________
LEARNING DISABILITIES?
YES _____ NO______ IF YES, PLEASE SPECIFY:_________________________________________________________
Corpus Christi Childcare Centre JK Daycare application does not guarantee the admission to Corpus Christi School. There
is adifferent applicationform tosummit.
PARENT / GUARDIAN’SNAME: _____________________________ SIGNATURE: _______________________
DATE: _____________________
Y/M/D
FAMILY INFORMATION
PARENTS
MOTHER’S NAME: _________________________ HOME PHONE: ___________________ CELL PHONE: ____________
OCCUPATION: ________________________ WORK PHONE: ______________________
DAYS/HOURS OF WORK:_________________ E-MAIL: ___________________________
FATHER’S NAME: ________________________ HOME PHONE: ___________________ CELL PHONE: _____________
OCCUPATION: ________________________ WORK PHONE: ______________________
DAYS/HOURS OF WORK:_________________ E-MAIL: ___________________________
SIBLIGNS
CHILD’S NAME: ___________________________________________________ BIRTHDATE: _____________________
FIRST NAME MIDDLE NAME LAST NAME Y/M/D
CHILD’S NAME: ___________________________________________________ BIRTHDATE: _____________________
FIRST NAME MIDDLE NAME LAST NAME Y/M/D
CHILD’S NAME: ___________________________________________________ BIRTHDATE: _____________________
FIRST NAME MIDDLE NAME LAST NAME Y/M/D
PERSON AUTHORIZED TO PICK UP THE CHILD AND BE CONTACTED IN CASE OF EMERGENCY. THESE PEOPLE
SHOULD BE AVAILABLE DURING HOURS OF CARE. (INCLUDE MOTHER/FATHER/GUARDIAN)
NAME: ___________________________________________ RELATIONSHIP TO CHILD: __________________________
HOME PHONE: ___________________ CELL PHONE: ______________________ WORK PHONE: __________________
NAME: ___________________________________________ RELATIONSHIP TO CHILD: __________________________
HOME PHONE: ___________________ CELL PHONE: ______________________ WORK PHONE: __________________
NAME: ___________________________________________ RELATIONSHIP TO CHILD: __________________________
HOME PHONE: ___________________ CELL PHONE: ______________________ WORK PHONE: __________________
IF APPROPIATE, LIST AN ENGLISH SPEAKING CONTACT:
NAME: ______________________________________________________ TELEPHONE: __________________________
CITIZENSHIP INFORMATION
STUDENT FATHER MOTHER
CANADIAN CITIZEN ____ CANADIAN CITIZEN ___ CANADIAN CITIZEN ___
LANDED IMMIGRANT ____ LANDED IMMIGRANT ____ LANDED IMMIGRANT ____
STUDENT VISA ____ STUDENT VISA ____ STUDENT VISA ____
PERMANENT RESIDENT OF BC ___ PERMANENT RESIDENT OF BC ___ PERMANENT RESIDENT OF BC ___
EMERGENCY INFORMATION
DOCTOR’S NAME: ____________________________________________ TELEPHONE: __________________________
B.C PERSONAL HEALTH CARE # ________________________________
In the event of emergency (Illness, earthquake, etc) my child may be released to the following people
NAME: ___________________________________________ RELATIONSHIP TO CHILD: __________________________
HOME PHONE: ___________________ CELL PHONE: ______________________ WORK PHONE: __________________
NAME: ___________________________________________ RELATIONSHIP TO CHILD: __________________________
HOME PHONE: ___________________ CELL PHONE: ______________________ WORK PHONE: __________________
HEALTH INFORMATION
Health professionals involved with your child (other than doctor and dentist)
NAME: _____________________________________ PROFESSION/AGENCY: __________________________________
PHONE: ______________________
NAME: _____________________________________ PROFESSION/AGENCY: __________________________________
PHONE: ______________________
DOES YOUR CHILD HAVE:
A MEDICAL CONDITION/CONCERN: YES______ NO______
IF YES, PLEASE PROVIDE FURTHER INFORMATION: _____________________________________________________
ALLERGIES: YES______ NO______
IF YES, PLEASE PROVIDE FURTHER INFORMATION: _____________________________________________________
ASTHMA: YES______ NO______
IF YES, PLEASE PROVIDE FURTHER INFORMATION: _____________________________________________________
HAS YOUR CHILD HAD A SEIZURE IN THE PAST YEAR? YES_____ NO______
IF YES, PLEASE PROVIDE FURTHER INFORMATION: _____________________________________________________
DOES YOUR CHILD REQUIRE A SPECIAL DIET RELATED TO A MEDICAL CONDITION? YES_____ NO_____
IF YES, PLEASE PROVIDE FURTHER INFORMATION: _____________________________________________________
FOOD SENSITIVITIES? YES______ NO______
IF YES, PLEASE PROVIDE FURTHER INFORMATION: _____________________________________________________
LIST ALL PRESCRIBTION AND “OVER THE COUNTER” MEDICATION YOUR CHILD RECEIVES:
MEDICATION TIMES GIVEN REASON FOR MEDICATION
_________________________ ________________________ ____________________________
_________________________ ________________________ ____________________________
_________________________ ________________________ ____________________________
YOU MAY BE ASKED TO COMPLETE ADDITIONAL FORMS IF YOU ANSWERED YES TO ANY OF THE ABOVE.
THIS HEALTH INFORMATION MAY BE MAY AVAILABLE TO THE STAFF OF VANCOUVER COASTAL HEALTH
CUSTODY AGREEMENT: YES____ NO____ N/A____ PROVIDED TO FACILITY: YES____ NO____ N/A____
IMMUNIZATION DOCUMENTS RETURNED TO FACILITY: YES____ NO____
INFORMATION PROVIDED BY:
NAME: _____________________________ SIGNATURE: _______________________ DATE: ______________________
Y/M/D
INFORMATION RECEIVED BY:
NAME: _____________________________ SIGNATURE: _______________________ DATE: ______________________
Y/M/D
I certify that am a permanent resident of British Columbia and the above information provided is correct.
SIGNATURE: _______________________ DATE: ______________________
Y/M/D
