Child Information

Child First Name*

Child Middle Name

Child Last Name*

Child's Address - Street Number and Name*

Child's Address - City*

Child's Address - Province*

Child's Address - Postal Code*

Date of Birth*

School Attending in Fall*

School Grade (in fall)*

Current School Attending*

Current Teacher's Name*

Separator

Parent Information

Mother/Guardian Full Name

Relationship to Child

Mother Email

Mother Home Phone #

Mother Work Phone #

Mother Cell Phone #

Mother Employer

Father/Guardian Full Name

Relationship to Child

Father Email

Father Home Phone #

Father Work Phone #

Father Cell Phone #

Father Employer

Status of Parents (i.e. together, separated, divorced, etc)

Emergency Contact Full Name (other than parent/guardian)*

Emergency Contact Phone #*

Separator

Pickup Permission

I give permission for the following people to pick up my child from Kids Connection (note: photo id will be required for picking up a child).

Pickup 1 Name

Pickup 1 Relationship to Child

Pickup 1 Phone #

Pickup 2Name

Pickup 2 Relationship to Child

Pickup 2 Phone #

Pickup 3 Name

Pickup 3 Relationship to Child

Pickup 3 Phone #

Separator

Health Information

Health Card Number*

Name of Doctor*

Doctor's Phone #*

Allergies

Medical Conditions

Physical Conditions

Behavioural/Social Conditions

Is there any other information about the care of your child that we need to know?

Emergency Medical Consent: I hereby give permission for the Supervisor and staff of Kids Connection to act on my
behalf in obtaining and/or authorizing medical treatment if an emergency arises and I cannot be contacted by telephone.
I understand that any treatment would be on the advice of a qualified medical doctor. Children are not to
bring medication to center. Staff do not administer drugs.

Medical information is collected solely to support your child's accommodation needs and will not be used to determine program eligibility.

Signature*

Date*

Separator

Fee Information and Payment Options

Program Option (prices subject to change)*

After-School Only ($335/month; 2nd child $305/month)

Before/After School ($360/month; 2nd child $335/month)

PD Days/Snow Days Only ($40/day)

March Break Day Camp ($150/wk or $75/wk if enrolled in after school program)

Add PD/Storm Days/Delays/Early Closures

Add PD/Storm Days ($20/day)

Add Delays ($5/day if After-School Only; $4/day if Before/After School)

Add Early Closures ($10/day)

Start Date*

Payment Method*

E-Transfer

Subsidy

Payment Frequency*

Bi-Weekly

Monthly

If subsidized, what is the parent share?

Name to Go On End-of-Year Receipt