Printable PDF version of the form available here: Registration Form View the SJD OSC Parent Handbook Step 1 of 6 16% Child's InformationCheck all that you're applying for* Before School Care After School Care Child's name*DOB (m/d/y)*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age as of December 31st, 2018*Gender*MSP #*Grade as of Sept 2018*Program start date (m/d/y)*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Alergies or medical conditions*Immunization*My child is immunizedI choose not to immunize my childFamily doctor (walk in clinic name & number required if no doctor)*Child's dentist and phone number*Siblings attend SJD OSC*YesNoName(s) & programs* Basic Schedule and Record of ImmunizationImmunization RecordI'll upload record of immunizationI'll submit the dates of immunizationUpload Record of Immunization* Drop files here or Accepted file types: jpg, jpeg, gif, png, bmp, tiff, tif, doc, docx, pdf. First Visit – two months of age:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Confirm Immunizations (1)* Select All Diphtheria Pertussis Tetanus Polio Haemophilus Influenza Type b (hib) Hepatitis B Pneumococcal Conjugate Meningococcal C Conjugate Second Visit – two months after first visit:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Confirm Immunizations (2)* Select All Diphtheria Pertussis Tetanus Polio Haemophilus Influenza Type b (hib) Hepatitis B Pneumococcal Conjugate Third Visit – two months after second visit:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Confirm Immunizations (3)* Select All Diphtheria Pertussis Tetanus Polio Haemophilus Influenza Type b (hib) Hepatitis B Pneumococcal Conjugate Fourth Visit – 12 months of age:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Confirm Immunizations (4)* Select All Measles Mumps Rubella Meningococcal C Conjugate Varicella (chicken pox) Fifth Visit – 12 months after third visit:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Confirm Immunizations (5)* Select All Diphtheria Pertussis Tetanus Polio Haemophilus Influenza Type b (hib) Measles, Mumps, Rubella Pneumococcal Conjugate 4 to 6 years of age:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Confirm Immunizations (6)* Select All Diphtheria Pertussis Tetanus Polio Varicella (chicken pox) Parent/Guardian InformationThe first parent/guardian listed below will be the primary contact for billing, tax recipient and communication purposes unless otherwise stated. A signature is required from both parents/guardians listed on this registration document.First Parent/GuardianParent/guardian name*Place of work*Relationship to child*Home address*Postal code*Home phone number*Work phone number*Work number Ext.*Cell Phone*Email*Second Parent/GuardianParent/guardian name*Place of work*Relationship to child*Home address*Postal code*Home phone number*Work phone number*Work number Ext.*Cell phone*Email* Primary Custody Residence of ChildPrimary Custody Residence of Child*Joint custodyWith fatherWith motherAttach documentation if applicable Custody Order Court Order Upload Custody Order*Accepted file types: jpg, jpeg, gif, png, bmp, tiff, tif, doc, docx, pdf.Upload Court Order*Accepted file types: jpg, jpeg, gif, png, bmp, tiff, tif, doc, docx, pdf.Authorized Pick-Up ContactsThe following people are authorized to pick-up my child from the Club:Name of Authorized person (1)Phone Number of Authorized person (1)Name of Authorized person (2)Phone Number of Authorized person (2)Name of Authorized person (3)Phone Number of Authorized person (3)Name of Authorized person (4)Phone Number of Authorized person (4)Name of Authorized person (5)Phone Number of Authorized person (5)Persons Not Permitted Access to ChildThe following people are not permitted access to my child:Name of Prohibited person (1)Phone Number of Prohibited person (1)Name of Prohibited person (2)Phone Number of Prohibited person (2)Name of Prohibited person (3)Phone Number of Prohibited person (3)Name of Prohibited person (4)Phone Number of Prohibited person (4)Emergency ContactsThree local contacts, 19+ other than parent/guardian, are required in the event of an emergency or to care for my child if my child is ill and the Club is unable to contact me:Emergency Contact Name (1)*Primary Phone # (1)*Secondary Phone # (1)Emergency Contact Name (2)*Primary Phone # (2)*Secondary Phone # (2)Emergency Contact Name (3)*Primary Phone # (3)*Secondary Phone # (3)Authorization* I authorize the staff at the Sir James Douglas Out of School Club Child Care facility to call a physician or summon an ambulance for emergency medical aid should the person(s) in attendance feel such services are required for my child. If such an emergency should arise, I shall be notified as soon as possible. I agree that any cost incurred for such services shall be the sole responsibility of myself. Permission I give permission for SJD school staff and the OSC to share communications. Permission I give permission for the Sir James Douglas Out of School Club Child Care facility (the Club) to send emails or newsletters. You can unsubscribe from the mailer at any time by emailing sjdoutofschollclub@gmail.com Additional Care Needs or Support Needs for your childAdditional Support My child requires additional support (behaviour/social/cognitive/physical) My child requires medication, please request a Permission To Administer Medication form My child has allergies/dietary needs Allergies/Dietary Needs*Care PlanI will upload a care planI would like to create a care planUpload Care Plan*Accepted file types: jpg, jpeg, gif, png, bmp, tiff, tif, doc, docx, pdf.Acknowledgement* I acknowledge that my child is not to be in possession of any medication while at the Club and that Club staff cannot administer medication to my child if a Permission to Administer Medications form has not been completed. Risk acknowledgement and assessmentAcknowledgement (1)* I waive any liability on the part of the Sir James Douglas Out of School Club (the Club) and any of its employees, directors, agents or representatives if my child is injured on the playground equipment, in the Club or on field trips away from the Club premises. I fully understand that reasonable precautions and safety measures will be taken by the Club staff; however, I acknowledge that children may receive injuries even under close supervision. Acknowledgement (2)* SJD OSC travels to out-trip locations by public transport, rental bus or on foot. I understand precautions and safety measures will be taken by the SJD OSC staff and acknowledge the risks associated with travel and transportation. Acknowledgement (3)* I waive any liability on the part of the Sir James Douglas Out of School Club (the Club) and any of its employees, directors, agents or representatives for any act or omission of any of its staff members hired by me to provide child care, housecleaning and other services. I understand that, if I/we hire staff of the Club, that the Club is not responsible and all risks associated with such engagements are born solely by me/us and the worker(s). I acknowledge that Club staff so engaged are not covered by the Club or Club’s insurance or WCB insurance. Child's PhotoChild's photo*Accepted file types: jpg, jpeg, gif, png, bmp, tiff, tif, doc, docx, pdf.A 4 x 6 colored photograph of your child is required. In the event of emergency, it is important that we be able to clearly identify your child from the provided photograph. (VIHA licensing requirement)Permission I give permission for pictures to be used in children’s art projects and on display within the centre and on our website and social media sites. Parental AgreementsAgreement (1)* I acknowledge and agree that the information that I have provided in this Registration Form is correct and complete. I further agree that we are responsible to, and that I will, advise the Club of any changes to this information in a timely manner. Agreement (2)* I have read the Sir James Douglas Out of School Club’s Parent Handbook including this Appendix A (Registration Form) and agree to all terms and conditions outlined in the Parent Handbook. (currently being revised completion fall 2018) I understand that compliance with the Parent Handbook and all other Club policies (current and as amended throughout the year) is a condition of my/our child’s continued enrolment in the Club. Agreement (3)* For the time my child is enrolled at Sir James Douglas Out of School Club, I agree to abide by the Club’s Policies including: To give at least one full months written notice (last day of the month preceding the last month of care) to the Club Director, prior to withdrawing my child from the centre (or forfeit one month's child care fees). To pay fees beginning September 15th . I am aware that no rebate of fees will be allowed for absence due to illness or any other reason; I am aware that non-payment of fees will result in loss of enrollment at the Club. To drop off my child directly to a staff member, advise staff of departures and use the sign- in/sign-out sheet posted. I also agree to adhere to program start and finish times. I understand that this policy is strictly enforced and a fine of $10.00 for every quarter hour or portion thereof, will be levied for tardy pickups. I understand that if I am repeatedly late, that this is grounds for the termination of my contract. To notify staff if my child is unable to attend the Club on any given day, due to illness, holidays, etc. If my child is ill, I will make other arrangements for his/her care and advise the Club of any communicable diseases including lice, that may affect other children, or the care of the child involved. To notify the Club Director, in writing of any changes, new information or special instructions regarding my child. To notify the Club Director in writing of any and all people authorized to deliver and/or pick up my child. To notify the Club Director in writing of any and all persons not permitted access to my child. Date of SigningMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of Parent/Guardian (1)Signature of Parent/Guardian (1)Name of Parent/Guardian (2)Signature of Parent/Guardian (2)EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
