Daycare Licensing Regulations do not permit us to care for your child until we have this completed Enrollment Record on file. Please print
clearly; use pen. Answer all questions and attach copies of your current Alberta Health Care Card and your child’s up to date immunization
record. Please advise director immediately of any changes in phone numbers, addresses, immunizations, allergies etc.
SECTION 1
A. CHILD’S INFORMATION
B. GUARDIAN INFORMATION/MOTHER
Mother/Guardian
Occupation
Employed by
Work Address
Working Hours
Home Address
Postal Code
Work Phone #
Cell Phone #
Home Phone #
Email address
Marital Status
C. GUARDIAN INFORMATION /FATHER
Father / Guardian
Occupation
Employed By
Work Address
Working Hours
Home Address
Postal Code
Work Phone#
Cell Phone #
Home Phone #
Email Address
Marital Status
D. FAMILY BACKGROUND
Mother Home Country
Mother’s Home Language
Father’s Home Country
Father’s Home Language
Child’s Home Country
Child’s Home Language
If parents are divorced or separated, how
long?
Child’s adjustment to this
Please notify who is responsible for payments and fees
Custody arrangements: (Provide Court Orders)
Person not allowed to pick up the child
E. ALTERNATE EMERGENCY CONTACT
Name
Phone
Relation to child
Work Phone #
Address
Can pick all children in the family:
Codeword to be used by persons picking up your child
F. FAMILY LIVING AT HOME OTHER THAN PARENTS AND SIBLINGS
Name
Age
Relation to
child
Name
Age
Relation to
child
G. EATING HABITS
Describe general appetite of your child
Is there anything we should know about what or how he/she eats?
Please mention feeding schedule, food already introduced, food to be introduced, special instructions and habit.
H. SOCIAL DEVELOPMENT
How would you describe your child’s personality?
Does your child sleep?:
Previous Daycare
I. HEALTH INFORMATION
Alberta Health Care Number
Doctor’s Name
Telephone
Address
Immunization is updated:
J. CHILDHOOD ILLNESS
Allergies: (Specify)
Other Dietary restrictions
Childhood illness (if any)
Hospitalization: (Date and Diagnosis)
Has your child had any medical or condition requiring or receiving treatment Or supervision?:
If yes please describe
Is your child on ongoing medication:
If yes what kind?
SECTION 2
A. PERMISSIONS AND ACKNOWLEDGEMENTS
To grant permission, in case of accident or illness, that emergency care be given, including emergency transportation ( if necessary in Good Start Daycare judgment), at my own expense.
To give one month notice of withdrawal.
To pay daycare fees in advance on or before the 1st working day of each month. I
understand late payments are subject to a late payment penalty of $50.00.
To have my child picked up by 6:00 P.M each evening or to pay the LATE PICK UP CHARGE of $ 1.00 for each minute per child after 6:00 that my child or children remains in the center’s care.
I Agree
Good Start Daycare has my permission to take my child on field trips under supervised
care:
Yes No
That I have read and understand all information in the parent handbook and that I was
given a tour:
Yes No
Orientation process (director explained all policies and procedures and gave a tour of the facility) is
completed by the director:
Yes No