Online Application

Child Personal Information

Full Name of Child*: Nickname: Address*:

Gender*: Date Of Birth*: Nationality*: Religion:

Attendance: Full DayHalf Day Class:

Parents/Guardian Information

Mother/Guardian

Mother/Guardian Name* Place And Address of Employment* ID / Passport Number* Email Cell Number* Work Number Address (if different from child’s)

Father/Guardian

Father/Guardian Name* Place And Address of Employment* ID / Passport Number* Email Cell Number* Work Number Address (if different from child’s)

Persons Authorized to Pick up Child ( other than parents / guardian )

First Person

Name: Relationship Home Number Work/Cell Number Collection Password:

Please specify:

Second Person

Name: Relationship Home Number Work/Cell Number Collection Password:

Please specify:

Emergency Contact (other than parents)

First Person

Name*: Relationship*: Home Number: Work/Cell Number*

Second Person

Name: Relationship: Home Number: Work/Cell Number

Emergency Health Information

Doctor’s Name/Clinic: Phone Number: Address: Child’s Care Card Number: Dentist’s Name/Clinic: Phone Number

Consent for Emergency Care

By clicking the checkbox below, I authorize the staff of Little Buddy and Friends to call a medical practitioner or ambulance in the case of accident or illness of my child, if the parents cannot be reached immediately. I Consent

Health Information (Please attach a separate sheet if necessary)

1. Regular medication (s) and reasons for (please list): 2. Allergies/Reactions and treatment (please list): 3. Any concerns/issues regarding your child’s health (seizures, asthma, vision, hearing, etc) (please list and describe): 4. Any concerns regarding your child’s development (behaviour, speech, language, mobility, etc) (please list and describe): 5. Please list any specific care instructions regarding #1-4: 6. Other health care professionals involved in your child’s life (Occupational Therapist/Physical Treatment, etc) :

Feeding Routine

1. Child appetite: 2. Does the family have meals together: 3. Child food preference or food to avoid:

Dominance

Child

Left HandedRight Handed

Biological Mother

Left HandedRight Handed

Biological Father

Left HandedRight Handed

Social Circumstances

Social Circumstances And Relationships

1. Describe the relationship and interactions between father and child, mother and child briefly 2. Describe your child’s relationship with his/her siblings 3. Whose authority does the child accept reality? Father/Mother/Both/Other ?

Family Information

1. Please list the name(s) of the significant people in your child’s life. [Fullname, Gender, Relationship, Age] (siblings, grandparents, etc): 2. Primary language spoken at home: 3. Other languages spoken at home:

Any Other Comments

Child Personal Information

Parents/Guardian Information

Mother/Guardian

Father/Guardian

Persons Authorized to Pick up Child ( other than parents / guardian )

First Person

Second Person

Emergency Contact (other than parents)

First Person

Second Person

Emergency Health Information

Consent for Emergency Care

Health Information (Please attach a separate sheet if necessary)

Feeding Routine

Dominance

Child

Biological Mother

Biological Father

Social Circumstances

Social Circumstances And Relationships

Personality

Emotional

Family Information