Kindercare Registration

Register online to save time! Fill out the form below to register your child for Kindercare or you may print out the form and fill it out here.

Child's Information

Child's Name *

First

Last

Sex *

Birth Date *

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Cell Phone *

Email *

Contact Information

Local Address / Accommodation *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mother's Name *

Father's Name *

Emergency Contact Name *

Emergency Contact Cell Phone *

Emergency Contact Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Names of persons authorized to pick up child from daycare *

Anyone who is not authorized to pick up child *

Medical Information

Family Doctor *

Phone *

Medical Insurance Plan Name

Health Card Number *

Immunizations *

Does this child have any known medical problems or diet restrictions? *

Instructions to follow in the event of an allergic reaction

Questionnaire

The following information will help us get to know your child more quickly and help us plan a program to enrich their daycare experience.

What activities does your child enjoy?

Please list any special words used at home for toileting, favorite items, family members, etc.

How does your child relate to other children?

Has your child had any previous daycare experiences?

Does your child have any particular fears?

How can we help with any separation anxiety?

Any additional remarks that will assist us in providing the best possible care for your child

Parental Consent

I hereby give my consent for the following: *

A digital image to be taken and saved of child in the case of an emergency.
For the caregivers to seek emergency medical treatment for my child if needed. I agree that any costs for such services shall be my responsibility.