on-site child care

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1Basic information

2About your child / fr*À propos de votre enfant

3Your child's personality

4Your child's experience in child care

5Your child's medical information / fr*Your child's medical information

6Consents and signature / fr*Consents and signature

Child's name *

First

Last

fr* child's Nom *

First

Last

Child's date of birth *

Your child will be enrolled as

fr*Child's Date of birth *

fr*Your child will be enrolled as

Parent's name *

First

Last

fr*Parent's Nom *

First

Last

Personal (non-work) email address *

Confirm Email

Adresse électronique personnelle : (pas au travail) *

Confirm Email

Personal (non-work) cell: *

Tél. cellulaire personnel (pas au travail) *

Local number

No de section locale

Union number

Numéro de syndicat

Home address

Adresse du domicile

Postal code

Code postal

When will you need childcare? (Please select all that apply) *

Wednesday Evening – 7pm-11pm
Thursday Day – 8am-5:30pm
Thursday Evening – 7pm-11pm
Friday Day – 8am-5:30pm
Friday Evening – 7pm-11pm
Saturday Day – 8am-5:30pm
Saturday Evening – 7pm-11pm
Sunday Day – 8am-12:30pm

fr*When will you need childcare? (Please select all that apply) *

fr*Wednesday Evening – 7pm-11pm
fr*Thursday Day – 8am-5:30pm
fr*Thursday Evening – 7pm-11pm
fr*Friday Day – 8am-5:30pm
fr*Friday Evening – 7pm-11pm
fr*Saturday Day – 8am-5:30pm
fr*Saturday Evening – 7pm-11pm
fr*Sunday Day – 8am-12:30pm

Emergency contacts and action plan

fr*Emergency contacts and action plan

Emergency contact name *

fr*Emergency contact name *

Emergency contact cellphone number *

fr*Emergency contact cellphone number *

Please indicate what steps should be taken in case of emergency: *

fr*Please indicate what steps should be taken in case of emergency: *

About your child

fr*About your child

Are you currently breastfeeding / chestfeeding? *

fr*Are you currently breastfeeding / chestfeeding? *

How frequently are you breastfeeding / chestfeeding? *

fr*How frequently are you breastfeeding / chestfeeding? *

To support an easy transition for your child, please provide the following information, if appropriate.

fr*To support an easy transition for your child, please provide the following information, if appropriate.

When should your child get a bottle, and how much in the bottle? *

fr*When should your child get a bottle, and how much in the bottle? *

What kind of food should your child get, and when? *

fr*What kind of food should your child get, and when? *

Does your child nap through the day? *

fr*Does your child nap through the day? *

At what times and for how long do they usually nap? *

fr*At what times and for how long do they usually nap? *

Please tell us your child's favourite toy, pet name(s), favourite book, and favourite person *

fr*Please tell us your child's favourite toy, pet name(s), favourite book, and favourite person *

If your child has any particular habits – such as thumb-sucking or nail-biting – please describe:

fr*If your child has any particular habits – such as thumb-sucking or nail-biting – please describe:

Does your child have any particular fears, such as dogs or sirens? Do they have nightmares?

fr*Does your child have any particular fears, such as dogs or sirens? Do they have nightmares?

Does your child have any words or expressions that may not be understood by a staff member?

fr*Does your child have any words or expressions that may not be understood by a staff member?

In general, how does your child react to a stressful situation? *

fr*In general, how does your child react to a stressful situation? *

If your child had any previous child care or play group experiences, please describe:

fr*If your child had any previous child care or play group experiences, please describe:

Has your child had the experience of being cared for by adults other than members of your family?  *

fr*Has your child had the experience of being cared for by adults other than members of your family? *

What is your accustomed method of reassuring and rewarding your child? Please describe: *

fr*What is your accustomed method of reassuring and rewarding your child? Please describe: (copy) *

What is your accustomed method of disciplining your child? What is your "philosophy" of discipline?  *

fr*What is your accustomed method of disciplining your child? What is your "philosophy" of discipline? *

Language(s) your child speaks *

English
French
Other

fr*Language(s) your child speaks *

fr*English
fr*French
fr*Other

Other language(s) your child speaks *

fr*Other language(s) your child speaks *

Your child is … *

Talkative
Quiet
Average

fr*Your child is … *

fr*Talkative
fr*Quiet
fr*Average

Does your child have any cognitive or physical conditions we should be aware of?

fr*Does your child have any cognitive or physical conditions we should be aware of?

Do you have any concerns about your child's eating habits? Please describe:

fr*Do you have any concerns about your child's eating habits? Please describe:

Do you have any concerns about your child's toilet habits? Please describe:

fr*Do you have any concerns about your child's toilet habits? Please describe:

Is your child physically able to take part in all program activities?  *

fr*Is your child physically able to take part in all program activities?  *

Teen Community Hours – We want to ask the parent if their 14 to 16 year old is interested in possibly earning some community hours for their high school diploma *

fr*Teen Community Hours – We want to ask the parent if their 14 to 16 year old is interested in possibly earning some community hours for their high school diploma *

Medical / allergy information

fr*Medical / allergy information

Does your child have a medical condition or any allergies?  *

fr*Does your child have a medical condition or any allergies?  *

Name of condition or type of allergy *

fr*Name of condition or type of allergy *

Reactions (signs and symptoms) *

fr*Reactions (signs and symptoms) *

Epipen required?  *

fr*Epipen required? *

Medication required?  *

fr*Medication required?  *

Comments (Medication dosage, schedule, special precautions, etc)  *

fr*Comments (Medication dosage, schedule, special precautions, etc)  *

Name of doctor *

fr*Name of doctor *

Doctor's contact number *

fr*Doctor's contact number *

Child's OHIP number  *

fr*Child's OHIP number *

The following four consent questions must be accepted, otherwise your child cannot be admitted into Kids Kamp program.

fr*The following four consent questions must be accepted, otherwise your child cannot be admitted into Kids Kamp program.

Medication consent *

Please give my child the medication listed above as directed

fr*Medication consent *

fr*Please give my child the medication listed above as directed

Medical consent *

Upon admission of my child to the OPSEU/SEFPO Child Care Program, I agree that in the event of an emergency when I cannot be reached, I authorize the administration of any medical procedures deemed necessary by a doctor or hospital selected.

fr*Medical consent *

fr*Upon admission of my child to the OPSEU/SEFPO Child Care Program, I agree that in the event of an emergency when I cannot be reached, I authorize the administration of any medical procedures deemed necessary by a doctor or hospital selected.

Release declaration *

I hereby release the Ontario Public Service Employees Union (OPSEU/SEFPO), its employees, and agents from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury (including death) that may be sustained by my child while participating or traveling to and from activity(ies).

fr*Release declaration *

fr*I hereby release the Ontario Public Service Employees Union (OPSEU/SEFPO), its employees, and agents from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury (including death) that may be sustained by my child while participating or traveling to and from activity(ies).

Damage declaration *

I agree to accept full responsibility, financially or otherwise, for any damage my child may do to the property of the child care facilities, properties visited on outings, other’s personal property or vehicles used for transportation.

fr*Damage declaration *

fr*I agree to accept full responsibility, financially or otherwise, for any damage my child may do to the property of the child care facilities, properties visited on outings, other’s personal property or vehicles used for transportation.

For the remaining consent questions, please select the most appropriate response for your child.

fr*For the remaining consent questions, please select the most appropriate response for your child.

Field trip consent *

I give consent for my child to go on all outings planned by the OPSEU/SEFPO on-site child care staff. I understand some trips may change or be rescheduled due to weather or other circumstances
Please provide specific information on outings for approval to be granted.
I do not consent to field trips

fr*Field trip consent *

fr*I give consent for my child to go on all outings planned by the OPSEU/SEFPO on-site child care staff. I understand some trips may change or be rescheduled due to weather or other circumstances
fr*Please provide specific information on outings for approval to be granted.
fr*I do not consent to field trips

Photos consent *

I consent to OPSEU/SEFPO taking photographs of my child while in OPSEU/SEFPO’s care
I do not consent to photos of my child

fr*Photos consent *

fr*I consent to OPSEU/SEFPO taking photographs of my child while in OPSEU/SEFPO’s care
fr*I do not consent to photos of my child

Register another child or dependent?

You must complete a separate form for each child or dependent. But we can reuse some of the information you entered on this form.

fr*Register another child or dependent?

fr*You must complete a separate form for each child or dependent. But we can reuse some of the information you entered on this form.

add child *

I’d like to register another child or dependent
I’m all done!

fr*add child *

fr*I’d like to register another child or dependent
fr*I’m all done!

Signature

Parent's name *

Signature attestation *

Consider my typed name as my signature

fr*Parent's name *

fr*Signature attestation *

fr*Consider my typed name as my signature