Childmind Program Registration

Immigration Status ( Choose One)

Enter the Permanent Resident Number

Name

Relationship (Choose one)

Father

Mother

Child

Permanent Resident Number

This form is intended to travel with a child in the event KIS staff must leave the facility with a child.

In the event of an emergency, KIS staff will keep this information and consent forms to access emergency medical treatment based upon the first aid and emergency information provided

Child's Name

First

Last

Child photo

Maximum file size: 67.11MB

Gender

Male

Female

Other

Date of Birth

Guardian's Name

First

Last

Phone

Address

City

State/Province

Zip/Postal

Alternate Contact

Relationship to you

Physician Name

Phone

Dentist

Phone

Care Card Number

Is Child fully Immunized

Last Date of Tetanus Shot

Child's Weight

Child's Height

Eye Color

Hair Color

Other distinguishing features

Alergies: if yes, list all; give symptoms; procedures

Start Date

Days Attending Childmind

Time

Person Authorised to pick up your Child

Person Not Authorised to pick up your child (A copy of legal custody orders are required in order to detain pickup by the parent)

The Kamloops Immigrant Services (KIS) Childminding Program policy is to notify a parent or guardian in the event a child is ill or needs medical attention. In such case, if we cannot reach you immediately and the child needs immediate medical help, we will take the child to the nearest emergency centre. We will take this consent form to the emergency centre. It serves as your consent to have your child treated by emergency services.
I authorize the staff at the KIS to call a physician, take my child to the nearest emergency centre or summon an ambulance for emergency medical aid should they feel this is required and I cannot be contacted. If such an emergency should arise, I shall be notified as immediately as possible.

I, ................................................................understand that in order to use the Childminding Services at KIS while I am attending LINC, settlement services and/or workshops, I must not leave the premises without my child for ANY reason. My child must not leave the premises without me unless in the case of emergency.

Signature

Clear

Date

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