Blumenort Christian Preschool

Registration Form
2012-2013
4 year old
Please indicate your first choice (1) and your second choice (2). We will do our best to
accommodate all requests.
Monday/Wednesday 12:45-3:15 ___ Tuesday/Thursday 9:30-12:00 ___
Child's Name: _________________________________
Date of Birth: ________________

M/F

Address: _______________________________________
Email Address: __________________________________
Home Phone: __________
Father: ________________

Cell Phone: __________

Workplace: ________________ Work Phone: __________

Mother: ________________

Cell Phone: __________

Workplace: ________________ Work Phone: __________

Siblings Names and Ages: ________________________________________________________
Manitoba Health Registration # __________

PHIN# _________________

Family Doctor: ________________ Phone: __________

Emergency Contacts:
Name: ________________

Phone: __________

Name: ________________ Phone: __________

Persons Authorized to Pick Up Child (other than parents):
Name: ________________

Name: ________________

Name: ________________

Allergies and/or medical, physical, developmental or emotional concerns relevant to the care of
your child:
_______________________________________________________________________

_______________________________________________________________________

CONSENT FORM
Medical Consent
In the event that my child, ____________, is ill or injured and I,
(parent(s)/guardian) ____________, can not be reached I give
consent for Blumenort Christian Preschool to refer my child to the
family physician or have my child transported to the nearest
hospital.
I also understand that should my child be transported by
ambulance, Blumenort Christian Preschool will have no
responsibility for the costs involved.
Signed: ________________
Date: ____________

Photography and Video Consent

I, ____________, give permission for my child, ____________, to
be photographed and/or video taped. I also give permission for
those photographs and video clips to be included in the memory
DVD that each child will receive at the end of the year.
Signed: ________________
Date: ___________