LAKEVIEW CHRISTIAN SCHOOL
Pre-School Registration Form
CHILD
Full Legal Name _________________________________________________________
LAST FIRST MIDDLE
Name child responds to ____________________________________________________
Address ________________________________________________________________
#, STREET CITY PC
Phone ________________________ Gender M ___F ___ Citizenship _______________
Date of Birth _______________________ Date of enrollment _____________________
Child’s first language ______________________ Second language _________________
DAYS REQUESTED (pls circle)
Morning or Afternoon Monday / Tuesday / Wednesday / Thursday / Friday
PARENT/GUARDIAN
Name __________________________________________________________________
Home address ___________________________________________ Phone __________
Place of Work ___________________________ Phone __________ Cell ____________
Name __________________________________________________________________
Home Address __________________________________________ Phone ___________
Place of work ____________________________ Phone ___________Cell ___________
Applicant lives with: both parents ___mother ___father ___other ___ (legal papers required)
SDA: Yes ___ No___ Field Trip Permission and off-campus activities: Yes ___No ___
MEDICAL INFORMATION
Family Doctor _____________________________________ Phone ________________
Family Dentist _____________________________________ Phone ________________
BC Care Card Number __________________________ Date effective ______________
OTHER CHILDREN LIVING AT HOME
Name _________________________________ Date of Birth ______________________
Name _________________________________ Date of Birth ______________________
ALTERNATE PERSON TO CALL/PICK UP CHILD IN CASE OF EMERGENCY
Name ________________________________ Relationship _________ Phone ________
Name ________________________________ Relationship _________ Phone ________
PERSONS (OTHER THAN PARENT/GUARDIAN) TO PICK UP CHILD FROM FACILITY
Name ________________________________ Relationship _________ Phone ________
Name ________________________________ Relationship _________ Phone ________
Name ________________________________ Relationship _________ Phone ________
HAS CHILD HAD PREVIOUS EXPERIENCE AWAY FROM HOME?
(Day Care, pre-school, church, etc.) Yes ___No ___
Where? ________________________________Dates of attendance _________________
Where there any problems? _________________________________________________
Special words used by child for toileting? ______________________________________
Pls. indicate any known health concerns _______________________________________
COMMENTS OR INSTRUCTIONS FOR CARE GIVER (pls indicate appropriate ones)
Medication _______________ Allergies _________________________ Epipen _______
Food dislikes ____________ Special eating habits ___________ Vision/Hearing ______
Special/therapeutic diet (for reasons of health, religion, ethnicity) ___________________
Special instructions from parent or health care professional ________________________
________________________________________________________________________
Indicate any illness or medical disabilities your child has (give dates) ________________
________________________________________________________________________
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Immunization schedule
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Indicate dates immunizations received
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1st visit @ 2 months
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2nd visit
2 months after first
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3rd visit
2 months after 2nd
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4th visit 12 mo of age
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5th visit 12 months after 3rd
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5-6 yrs
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Grade 6
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Grade 9
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Diphteria
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*
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*
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*
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*
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*
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*
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Pertussis
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*
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*
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*
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*
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*
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Tetanus
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*
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*
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*
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*
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*
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*
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Poliomyelitis
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*
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*
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*
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*
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*
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HIB 1
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*
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*
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*
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*
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Measles, Mumps, Rubella
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*
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* 3
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Hepatitis B
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* 2
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* 2
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* 2
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*
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Pneumococcal Conjugate
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* 4
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* 4
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* 4
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* 4
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* 6
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Meningococcal C Conjugate
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* 5
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1 Protects against Haemophilus Influenzae B which may cause Meningitis
2 Hepatitis B immunization program for children born on or after Jan 1, 2001
3 Grade 6 Hepatitis B for children who were not previously immunized
4 Pneumococcal Conjugate for children born on or after July 1, 2002
5 Meningococcal C Conjugate for children born after July 1, 2002
6 Grade 6 meningococcal C for children who were not previously immunized
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(You are responsible for keeping a record of your child’s immunization).
Yes _____ I hereby give consent for a staff member to call a medical practitioner or ambulance for my child in the case of an accident, if I cannot immediately be reached.
__________________________________ _____________________
parent/guardian signature date
PARENT CONTRACT
I certify that the statements contained herein are true and correct to the best of my knowledge, knowing that willfully withholding or misrepresenting information may result in refusal of admission or dismissal from care/pre-school.
I have read the Lakeview Pre-School Handbook and voluntarily agree to uphold the ideals and standards set forth therein, and pledge my cooperation and loyalty, once my child is admitted.
My financial obligations are clearly understood and I agree to pay accordingly.
___________________________________ ________________________
parent/guardian signature date
