    Centres Éducatifs

    --------

    Educational Daycares

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Register a Child

Information Child

Daycare Choice

Ile Bizard Les Petits Boubou St-Luc Pierrefonds Ste-Anne Vaudreuil (VD1) Vaudreuil-Dorion 2 (VD2)

First Name

Last Name

This child lives with

Mother Father Mother and Father Other

Does this child have a brother or sister currently attending les Centres Éducatif à Ciel Ouvert?

Yes No

Language Spoken

French English French and English Other

Language Understood

French English French and English Other

Sex

Boy Girl

Date of Birth/Expecting Date

Desired Start Date

Is this the child of a staff member from Centre Educatif à Ciel Ouvert?

No Yes

Do you wish to join the breakfast program at $2 day?

No Yes

Does the child require sunscreen?

No Yes

Does the child require more than 10 hours of services per day?

No Yes

Medical Information

Does this child have allergies?

No Yes

Does this child have special medical or nutritional needs?

No Yes

Doctor name and address

Medical Information

Name of the Relevé 24

I authorize the daycare to administer the following

Diaper Cream

Yes No

Diaper Cream Instructions

Sunscreen

Yes No

Sunsreen Instructions

Nasal Drops

Yes No

Nasal Drops Instructions

Oral Hydrotation Solution

Yes No

Oral Hydrotation Solution Instructions

Calamine Lotion

Yes No

Calamine Lotion Instructions

Lip Balm

Yes No

Lip Balm Instructions

Moisturizing Cream

Yes No

Moisturizing Cream Instructions

Lubrificating Gel (in single dose format)

Yes No

Lubrificating Gel Instructions

Acetaminophene Authorization

Yes No

Photo

Yes No

Emergency Contact

Full Name

Telephone

Address

Relation

Authorized People

Provide up to 4 individuals authorized to pick-up your child.

First Authorized Person

Full Name

Telephone

Address

Relation

Second Authorized Person

Full Name

Telephone

Address

Relation

Third Authorized Person

Full Name

Telephone

Address

Relation

Forth Authorized Person

Full Name

Telephone

Address

Relation

+

-

Information Parent A

Relation

Mother Father Tutor Other

First Name

Last Name

Email

Home Phone

Address

Preferred Language

English French

Have you received your permanent residence in the past five years?

Yes No

Specify Additional Information

Work Phone

Cell Phone

Information Parent B

Relation

Mother Father Tutor Other

First Name

Last Name

Email

Preferred Language

English French

Specify Additional Information

Home Phone

Work Phone

Cell Phone

Address

Have you received your permanent residence in the past five years?

Yes No

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