Registration Form

Printable PDF version of the form available here: Registration Form

View the SJD OSC Parent Handbook

Step 1 of 6

Child's Information
Check all that you're applying for*
- Before School Care
- After School Care
Name
First Last
Child's first name*
Child's last name*
DOB (m/d/y)*
Age as of December 31st*
Gender*
MSP #*
Grade as of Sept*
Program start date (m/d/y)*
Alergies or medical conditions*
Immunization*
- My child is immunized
- I choose not to immunize my child
Family doctor name*

(walk in clinic name & number required if no doctor)
Family doctor number*

(walk in clinic name & number required if no doctor)
Child's dentist name*
Child's dentist phone number*
Siblings attend SJD OSC*
- Yes
- No
Name(s) & programs*

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Parent/Guardian Information
The 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/Guardian
Parent/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/Guardian
Parent/guardian name*
Place of work*
Relationship to child*
Home address*
Postal code*
Home phone number*
Work phone number*
Work number Ext.*
Cell phone*
Email*

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Primary Custody Residence of Child
Primary Custody Residence of Child*
- Joint custody
- With father
- With mother
Attach documentation if applicable
- Custody Order
- Court Order
Upload Custody Order*
Accepted file types: jpg, jpeg, gif, png, bmp, tiff, tif, doc, docx, pdf, Max. file size: 256 MB.
Upload Court Order*
Accepted file types: jpg, jpeg, gif, png, bmp, tiff, tif, doc, docx, pdf, Max. file size: 256 MB.
Authorized Pick-Up Contacts
The 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 Child
The 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 Contacts
Three 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

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Parental Agreements
Agreement (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 2021) 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:
Agreement (4)*
- I understand that Sir James Douglas Out of School Club is a parent owned and run co-operative. We require parents or guardians to participate in an Annual General Meeting and are in need of board members and directors.
Agreement (5)*
- I understand the Sir James Douglas Out of School Program runs from 7:30am to 6:00pm. The charge for late pick-up is $10.00 for every quarter hour or portion thereof.
- 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 Signing
Name of Parent/Guardian (1)
Signature of Parent/Guardian (1)
Name of Parent/Guardian (2)
Signature of Parent/Guardian (2)
Email
This field is for validation purposes and should be left unchanged.

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Sir James Douglas Out Of School Club

Registration Form

Step 1 of 6

Child's Information

Basic Schedule and Record of Immunization

Parent/Guardian Information

First Parent/Guardian

Second Parent/Guardian

Primary Custody Residence of Child

Authorized Pick-Up Contacts

Persons Not Permitted Access to Child

Emergency Contacts

Additional Care Needs or Support Needs for your child

Risk acknowledgement and assessment

Parental Agreements

sjdoutofschoolclub

Program Cell Phone Numbers