Kains Centre CEY Child Care Kains Centre 2146 Kains Rd, London, ON N6K 0C1 Director : Shakeel Shaikh and Chetan Agrawal Phone Number: (519) 472 - 4499 Email Address: Supervisor.kains@ceychildcare.com Book A Tour Admission Form 1Child Information2Health Information3Allergy Information4Consent5Agreement6About Child Child InformationSelect Your Childcare Location(Required)Select Your Childcare LocationCEY Child Care Thorold Centre - 15 Front St N, Thorold, ON L2V 1X3CEY Child Care Garrison Centre - 315 Garrison Rd, Fort Erie, ON L2A 0G2CEY Child Care Fort Erie Centre - 1264 Garrison Rd, Fort Erie, ON L2A 1P1CEY Child Care London Centre - 375 Horton St E, London, ON N6B 1L6CEY Child Care Wellington Centre - 100 Wellington Road, Units – E,F&G, London, ON, N6C 4M8CEY Child Care Huron Centre - 349 Main St S Exeter, ON N0M 1S6CEY Child Care Drayton Centre - 89 Wellington St S, Drayton, ON N0G 1P0CEY Child Care Calgary Centre - Unit 8 and 8A 3364 32 Street NE CalgaryCEY Child Care Collingwood Centre - 58 George St, Collingwood, ON L9Y 2E4CEY Child Care Innisfil Centre - 2383, 25th Side Road , Innsifil ON L9S 2G3CEY Child Care Nur Kids Centre - 89 Mill St N, Brampton, ON L6X 1T5CEY Child Care Kains Centre - 2146 Kains Rd, London, ON N6K 0C1Type of Child Care Required(Required) Full-Time Part-Time Extended Other Age Group Placement at Time of Enrolment(Required) Infant Toddler Preschool Hours of care(Required) Monday Tuesday Wednesday Thursday Friday Full Legal Name(Required)Preferred Name(Required)Date of Birth(Required) DD slash MM slash YYYY Age (years, months)(Required)Address(Required) Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code LANGUAGE(S) SPOKEN AT HOME(Required)OTHER CHILDREN IN THE FAMILY ENROLLED IN THE CENTRE (LIST NAMES, IF APPLICABLE)Parent InformationFull Legal Name(Required)Preferred NameRelationship to Child(Required)Primary Phone Number(Required)Alternate Phone NumberEmail Address 1(Required) Email Address 2 Parent's Home Address Same as Child Parent's Home Address Same as Child Parent's Street Address(Required) Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Custody Arrangements (if applicable)Are there custody arrangements pertaining to legal right of access to your child?*(Required) Yes No If YES, please provide a copy of the appropriate legal documentation (e.g., court order) Name(s) of custodial parent(s)(Required)Name(s) of individuals prohibited from accessing/picking up your childEmergency ContactsFull Legal Name(Required)Preferred NameRelationship to Child(Required)Primary Phone(Required)Alternate PhoneAuthorized to pick-up child(Required) Yes No Address(Required) Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Add More Emergency Contact Details?(Required) Yes No Emergency Contacts 2 DetailsFull Legal Name(Required)Preferred NameRelationship to Child(Required)Primary Phone(Required)Alternate PhoneAuthorized to pick-up child(Required) Yes No Address(Required) Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Emergency Contact 3 DetailsFull Legal NamePreferred NameRelationship to ChildPrimary PhoneAlternate PhoneAuthorized to pick-up child Yes No Address Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Pick-Up AuthorizationThe following additional individuals are authorized to pick up my child (Photo ID will be required to confirm identify before the child will be released) 1. Full Legal Name(Required)Relationship to Child(Required)Primary Phone(Required)More Individual Details to Pick Up My Child(Required) Yes No 2. Full Legal Name(Required)Relationship to Child(Required)Primary Phone(Required)3. Full Legal Name(Required)Relationship to Child(Required)Primary Phone(Required)Additional Emergency Information Please provide any special medical or additional information about your child that could be helpful in an emergency (e.g., known medical conditions, skin conditions, vision/hearing difficulties): Additional Emergency Information If your child has had any history of communicable diseases (e.g., chicken pox, measles), please list them below (see Appendix C for common communicable diseases from Health Canada): If your child has had any history of communicable diseasesDoes your child have any medical need(s) that requires additional support (e.g., Diabetes)?(Required) Yes No If yes, an individualized plan for children with medical needs must be developed between the parent and the child care centre prior to the child’s first day of care. Immunization RecordsNote: Please provide copy of updated Immunization record Please provide a copy of your child’s immunization record (e.g., yellow card) to the centre prior to your child’s first day of care. If you do not have an immunization record, please complete the chart below. If you have chosen not to immunize your child, a Statement of Medical Exemption form or a Statement of Conscious or Religious Belief form must be completed and provided to the centre. These forms are available on the Ministry of Education’s website. DTaP-IPV-Hib (2mos, 4mos, 6mos, 18mos) Diphtheria, Tetanus, Pertussis, Polio, Haemophilus influenzae type b:DTaP-IPV-Hib Dose1 Date MM slash DD slash YYYY DTaP-IPV-Hib Dose2 Date MM slash DD slash YYYY DTaP-IPV-Hib Dose3 Date MM slash DD slash YYYY DTaP-IPV-Hib Dose4 Date MM slash DD slash YYYY Pneu-C-13 (2mos, 4mos) Pneumococcal Conjugate 13: Pnec-C-13 Dose1 Date MM slash DD slash YYYY Pnec-C-13 Dose2 Date MM slash DD slash YYYY Pnec-C-13 Dose3 Date MM slash DD slash YYYY Pnec-C-13 Dose4 Date MM slash DD slash YYYY Rot-1 (2mos, 4mos) RotavirusRot-1 Dose1 Date MM slash DD slash YYYY Rot-1 Dose2 Date MM slash DD slash YYYY Rot-1 Dose3 Date MM slash DD slash YYYY Rot-1 Dose4 Date MM slash DD slash YYYY Men-C-C (12mos) Meningococcal Conjugate CMen-C-C Dose1 Date MM slash DD slash YYYY Men-C-C Dose2 Date MM slash DD slash YYYY Men-C-C Dose3 Date MM slash DD slash YYYY Men-C-C Dose4 Date MM slash DD slash YYYY Var (15mos) VaricellaVar Dose1 Date MM slash DD slash YYYY Var Dose2 Date MM slash DD slash YYYY Var Dose3 Date MM slash DD slash YYYY Var Dose4 Date MM slash DD slash YYYY MMRV (4-6years) Measles, Mumps, Rubella, VaricellaMMRV Dose1 Date MM slash DD slash YYYY MMRV Dose2 Date MM slash DD slash YYYY MMRV Dose3 Date MM slash DD slash YYYY MMRV Dose4 Date MM slash DD slash YYYY Tdap-IPV (4-6years) Tetanus, diphtheria, pertussis, PolioTdap-IPV Dose1 Date MM slash DD slash YYYY Tdap-IPV Dose2 Date MM slash DD slash YYYY Tdap-IPV Dose3 Date MM slash DD slash YYYY Tdap-IPV Dose4 Date MM slash DD slash YYYY Inf (every year in the fall) InfluenzaInfluenza Dose1 Date MM slash DD slash YYYY Influenza Dose2 Date MM slash DD slash YYYY Influenza Dose3 Date MM slash DD slash YYYY Influenza Dose4 Date MM slash DD slash YYYY Other (please specify)Other Vaccine Dose1 Date MM slash DD slash YYYY Other Vaccine Dose2 Date MM slash DD slash YYYY Other Vaccine Dose3 Date MM slash DD slash YYYY Other Vaccine Dose4 Date MM slash DD slash YYYY Other Vaccine(s) Allergy InformationDoes your child have a life-threatening allergy (e.g., anaphylactic to peanuts or bee stings)?(Required) Yes No If yes, an individualized plan for an anaphylactic allergy that includes emergency procedures must be developed between the parent and the child care centre prior to the child’s start date.Does your child have any allergies that are not life-threatening (food or other substance [e.g., latex])?(Required) Yes No If yes, please provide relevant details, including what your child is allergic to, symptoms of a reaction and treatment required:*(Required)Dietary and Feeding ArrangementsDoes your child have any special feeding arrangements (e.g., no sippy cups, mashed/pureed food)?(Required) Yes No If yes, please provide relevant details:(Required)Does your child have any special dietary requirements or restrictions (e.g., vegetarian, kosher, halal)?(Required) Yes No If yes, please provide relevant details:(Required)Sleep ArrangementsHow many naps does your child typically have each day?At what times does your child typically nap?How long does your child usually nap?Does your child have any special sleep requirements (e.g., specific comfort item, soother)? Yes No If yes, please provide relevant details:(Required) Consent/Agreement Form*Please read the following policies and procedures and initial your understanding of the policy and your willingness to abide by it by checking the boxI/We agree to read the Policy Manual of CEY Daycare and follow policies set out in it.(Required) I/We agree to read the Policy Manual of CEY Daycare and follow policies set out in it.(Required)I/We will bring our child(ren) into the classroom and greet the teacher at drop off and pickup times to exchange pertinent information and ensure supervision.(Required) I/We will bring our child(ren) into the classroom and greet the teacher at drop off and pickup times to exchange pertinent information and ensure supervision.(Required)I/We will keep CEY and/or program staff informed of changes in information relevant to my child, i.e., file information such as telephone numbers, change in child’s health, unusual happenings at home etc.(Required) I/We will keep CEY and/or program staff informed of changes in information relevant to my child, i.e., file information such as telephone numbers, change in child’s health, unusual happenings at home etc.(Required)I/We will keep payments current and up to date and paid in advance. Fees are due for statutory holidays and any other absent days (for illness or any reason) and any closure of the centre in the event of an emergency(Required) I/We will keep payments current and up to date and paid in advance. Fees are due for statutory holidays and any other absent days (for illness or any reason) and any closure of the centre in the event of an emergency(Required)I/We hereby consent to have my child leave the premises of The CEY from time to time, to participate in excursions to places of interest, planned as part of the children’s program. It is understood that members of the staff will provide supervision and every precaution will be taken for the safety of the child. Parents will also receive written notification prior to each full day field trip or excursion.(Required) I/We hereby consent to have my child leave the premises of The CEY Daycare Centre from time to time, to participate in excursions to places of interest, planned as part of the children’s program. It is understood that members of the staff will provide supervision and every precaution will be taken for the safety of the child. Parents will also receive written notification prior to each full day field trip or excursion.(Required)I/We grant permission for the operator or designate of The CEY Daycare Centre to take any necessary steps to obtain emergency medical care if warranted. A full outline of emergency procedures, policies and practices is in the Policy Manual. Any expenses incurred during an emergency will be the responsibility of the child’s family.(Required) I/We grant permission for the operator or designate of The CEY Daycare Centre to take any necessary steps to obtain emergency medical care if warranted. A full outline of emergency procedures, policies and practices is in the Policy Manual. Any expenses incurred during an emergency will be the responsibility of the child’s family.(Required)Any parent who arrives to pick up their child after their pre-determined scheduled times will be required to pay a late fee. In the event that the parent is late to pick up their child on more than 2 occasions the family may be withdrawn from the program.(Required) Any parent who arrives to pick up their child after their pre-determined scheduled times will be required to pay a late fee. In the event that the parent is late to pick up their child on more than 2 occasions the family may be withdrawn from the program.(Required)The CEY Daycare Centre reserves the unilateral right to cancel any arrangements, if policies of CEY Daycare are not followed by a child or parent.(Required) The CEY Daycare Centre reserves the unilateral right to cancel any arrangements, if policies of CEY Daycare are not followed by a child or parent.(Required)The CEY Daycare Programs will not be responsible for any incident that may occur as a result of false information given at the time of enrollment. I/We understand that my child(ren)s enrollment is contingent on all information outlined in these forms to be full and accurate.(Required) The CEY Daycare Programs will not be responsible for any incident that may occur as a result of false information given at the time of enrollment. I/We understand that my child(ren)s enrollment is contingent on all information outlined in these forms to be full and accurate.(Required)I/We give consent for the appearance of my/our child to appear in any publicity arranged by The CEY Daycare Centre through the various media, newspapers, radio, television, slide presentation and other publicity or educational purposes. This publicity may be in the form of photographs, video, writing pieces, and artwork with child’s first name It is felt that it is important for the community to be kept informed of activities of the program.* Yes, I agree No, I do not agree We have read the above policies and fully understand all of the above information:1. Name of Parent/Guardian(Required)1. Relationship to Child(Required)1. Date of Consent Agreement(Required) DD slash MM slash YYYY 2. Name of Parent/Guardian2. Relationship to Child2. Date of Consent Agreement DD slash MM slash YYYY Parent/Family Handbook and Fee AgreementChild's NameMonthly Child Care FeesAdmitted to Program (Room)Start Date DD slash MM slash YYYY I/We (the undersigned) have read the parent handbook for CEY Child Care and understand all the information, policies and procedures outlined in the handbook. By signing this agreement, we consent to all the handbook policies, procedures and agree to them. Including payment policies and late fees procedures. By signing this agreement, I/we acknowledge that the information supplied in the registration form regarding my/our child. The information supplied below is true and accurate to the best of my/our knowledge. 1. Name of Parent/Guardian Signed1. Relationship to Child1. Date Signed DD slash MM slash YYYY 2. Name of Parent/Guardian Signed2. Relationship to Child2. Date Signed DD slash MM slash YYYY Name of SupervisorDate Signed by Supervisor DD slash MM slash YYYY CEY Child’s NameMy First Day will beMy ClassroomMy TeacherHave been to daycare before Yes No Home Daycare or CentreLanguage Spoken at HomeSiblingsI Like or Enjoy:My Favourite things to do are:My fears are:Potty Trained Yes No How I ask to go to the Bathroom:Need a little bit help with:If having a bad day this is sure will cheer me up:We would love to hear about your Celebrations/Traditions, if you would like to share:Other things My Teacher needs to know:
