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Home
About
Programs
Partnerships
Open New Chapter
Contact
Admission Form
CEY Chapters

Home
About
Programs
Partnerships
Open New Chapter
Contact
Admission Form
CEY Chapters

CEY Chapters

Home
About
Programs
Partnerships
Open New Chapter
Contact
Admission Form
CEY Chapters

Home
About
Programs
Partnerships
Open New Chapter
Contact
Admission Form
CEY Chapters

Wellington Centre

CEY Child Care Wellington Centre

100 Wellington Road, Units – E,F&G, London, ON, N6C 4M8

Phone Number: (519) 645-0030

Book A Tour

Admission Form

1Child Information

2Health Information

3Allergy Information

4Consent

5Agreement

6About Child

Child Information

Select Your Childcare Location(Required)

Type 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 Province Postal Code

LANGUAGE(S) SPOKEN AT HOME(Required)

OTHER CHILDREN IN THE FAMILY ENROLLED IN THE CENTRE (LIST NAMES, IF APPLICABLE)

Parent Information

Full Legal Name(Required)

Preferred Name

Relationship to Child(Required)

Primary Phone Number(Required)

Alternate Phone Number

Email Address 1(Required)

Email Address 2

Parent's Home Address Same as Child

Parent's Street Address(Required)

Street Address City Province Postal Code

Custody Arrangements (if applicable)

Are there custody arrangements pertaining to legal right of access to your child?*(Required)

Yes

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 child

Emergency Contacts

Full Legal Name(Required)

Preferred Name

Relationship to Child(Required)

Primary Phone(Required)

Alternate Phone

Authorized to pick-up child(Required)

Yes

Address(Required)

Street Address City Province Postal Code

Add More Emergency Contact Details?(Required)

Yes

Emergency Contacts 2 Details

Full Legal Name(Required)

Preferred Name

Relationship to Child(Required)

Primary Phone(Required)

Alternate Phone

Authorized to pick-up child(Required)

Yes

Address(Required)

Street Address City Province Postal Code

Emergency Contact 3 Details

Full Legal Name

Preferred Name

Relationship to Child

Primary Phone

Alternate Phone

Authorized to pick-up child

Yes

Address

Street Address City Province Postal Code

Pick-Up Authorization

The 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

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 diseases

Does your child have any medical need(s) that requires additional support (e.g., Diabetes)?(Required)

Yes

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 Records

Note: 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) Rotavirus

Rot-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 C

Men-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) Varicella

Var 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, Varicella

MMRV 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, Polio

Tdap-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) Influenza

Influenza 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 Information

Does your child have a life-threatening allergy (e.g., anaphylactic to peanuts or bee stings)?(Required)

Yes

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

If yes, please provide relevant details, including what your child is allergic to, symptoms of a reaction and treatment required:*(Required)

Dietary and Feeding Arrangements

Does your child have any special feeding arrangements (e.g., no sippy cups, mashed/pureed food)?(Required)

Yes

If yes, please provide relevant details:(Required)

Does your child have any special dietary requirements or restrictions (e.g., vegetarian, kosher, halal)?(Required)

Yes

If yes, please provide relevant details:(Required)

Sleep Arrangements

How 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

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 box

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 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 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)

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 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/Guardian

2. Relationship to Child

2. Date of Consent Agreement

DD slash MM slash YYYY

Parent/Family Handbook and Fee Agreement

Child's Name

Monthly Child Care Fees

Admitted 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 Signed

1. Relationship to Child

1. Date Signed

DD slash MM slash YYYY

2. Name of Parent/Guardian Signed

2. Relationship to Child

2. Date Signed

DD slash MM slash YYYY

Name of Supervisor

Date Signed by Supervisor

DD slash MM slash YYYY

CEY Child’s Name

My First Day will be

My Classroom

My Teacher

Have been to daycare before

Yes

Home Daycare or Centre

Language Spoken at Home

Siblings

I Like or Enjoy:

My Favourite things to do are:

My fears are:

Potty Trained

Yes

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:

Canada Early Years believes in a future where every child, regardless of their socio-economic background, has access to quality early childhood education. As a dedicated non-profit organization, we are committed to providing Inclusive, accessible, and innovative childcare solutions that empower families and strengthen communities.

Quick Links

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Explore our various CEY Chapters in Ontario to find the perfect fit for your child’s early education.

Email: info@ceychildcare.com