Online Registration and Docs – Mercy Land Nursery School

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Child First Names *

Start with name Child responds to.

Child Last Name *

Child Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Child Date of Birth *

Gender *

Child Home Primary Contact Number *

Mother's Full Names

Mother's Contact Number *

Mother's Address if Different from Child's

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Mother's Place of Employment *

Name of Company Working Form or Type of Employment if employed.

Mother's Work Contact Number

Father's Full Names

Father's Contact Number *

Father's Address if Different from Child's

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Father's Place of Employment *

Name of Company Working Form or Type of Employment if employed.

Father's Work Contact Number

People Authorized to Pickup Child *

Please write in this format: Full Names, Contact Number, Relationship (User commas to separate information. E.g: John Doe, 076 123 4567, Uncle

Emergency Contact 1 Full Names

Emergency Contact 2 Full Names

Emergency Contact 3 Full Names

Emergency Contact 1 Contact Number

Emergency Contact 2 Contact Number

Emergency Contact 3 Contact Number

People NOT AUTHORIZE OR NOT ALLOWED to Pickup your Child *

Please write in this format: Full Names, Contact Number, Relationship (User commas to separate information. E.g: John Doe, 076 123 4567, Uncle

Emergency Health Information

Child Care Number

Authorization

I authorize the staff of Mercy land Nursery School to call a medical practitioner or ambulance in the case of accident or illness of my child, if the parents cannot be reached immediately.

Dr's or Clinic Name(s) *

Doctors Contact Number *

Dentist Name(s) *

Dentist Contact Number *

Emergency Health Information

1) Regular medication (s) and reasons for (please list):

3) Any concerns/issues regarding your child’s health (seizures, asthma, vision, hearing, etc) (please list and describe):

5) Please list any specific care instructions regarding #1-4:

2) Allergies/Reactions and treatment (please list):

4) Any concerns regarding your child’s development (behaviour, speech, language, mobility, etc) (please list and describe):

6) Other health care professionals involved in your child’s life (Occupational Therapist/Physical Treatment, etc):

Group Experiences

1) Has your child had previous nursery experiences? If yes, how did he/she adapt?

2) What is/are your child’s favourite toys/activities?

3) How does your child behave around other children (seeks others out, feels shy, etc)?

Emotional

1) How does your child react when left with unfamiliar people and/or in unfamiliar situations?

2) What suggestions do you have that would help staff ease your child’s transition into the program?

Family Information

1) Please list the name(s) of the significant people in your child’s life (siblings, grandparents, etc):

2) Primary language spoken at home:

Other languages spoken at home:

Any other comments:

Photo Documentation

Documenting the Centre’s activities is a part of our program. From time to time your child’s picture may be taken. Pictures taken will be used as displays in the classroom only.

Consent

I understand that photos may be taken of my child as they take part in the daily activities at the nursery. I give the staff of Mercy land Nursery School permission to take photos and display in the classroom.

Facebook Photo Documentation Consent

Mercy land Nursery School has its own Facebook page. This page is a place to communicate, see updates on the nursery, view pictures of your child’s day, and for people to see firsthand what Mercy land Nursery School is all about. To post any photos, Mercy land Nursery School needs your written consent to do so. Please fill out the appropriate section below.

Consent

I give Mercy land Nursery School permission to post photos of my child, , on their Facebook page. I understand that these photos can be viewed by anyone who uses Facebook.
I do not give Mercy land Nursery School permission to post photos of my child on their Facebook page.