Fraser River CEC-Centre of Early Childhood Development & Family Services Application Form

School Age Registration(5-12 Years Old)

Child Information

School Information

Parent/Guardian 1 Contact Information

Parent/Guardian 2 Contact Information

Emergency Contact Information

Child Health Information

Please indicate and comment on the following health areas and provide any additional special instructions for the provision of care for your child

Medications:

Is your child immunized against communicable illness?

In Case of Illness or Injury
I hereby give permission for the center staff or their representative to call an ambulance for transportation to the nearest hospital if needed. I understand that all costs incurred are the responsibility of the parent /guardian.

Parent/Guardian Signature Date