 |
Mail or Fax your form to us
To MAIL or PRINT the following
form: |
|
|
Mail or Fax your form to us
To MAIL or PRINT the following
form: |
AGAPE REGISTRATION
Student Information
Surname: Given Names:
Birthdate: Age: Sex:
Health Care #:
Does your child have any physical difficulties/delays?
If so, has there been any formal assessment done?
Does your child have any allergies? (eg. food, animals, etc)
List some hobbies/special interest your child has:
Has your child had any reoccurring medical problem or surgery for anything in the past?
Is your child presently on medication? Yes( ) No( )
If so, what type?
Family Information
Father’s Name: Address:
Phone number: Email:
Mother’s Name: Address:
Phone number:
Child lives with: Both Parents ( ) Father ( ) Mother ( ) Guardian ( )
Father’s Work Place: Business Phone:
Mother’s Work Place: Business Phone:
Brother’s Names Ages
Sister’s Names Ages
If your phone number or address changes throughout the year, then please notify the office immediately of these changes.
Emergency Contact Information (Essential Information)
A. Alternative Person(s) to contact in case of emergency:
Name:
Address:
Phone number (home):
Phone number (business):
Relation to Child:
B. Authorized Person(s) to Whom Your Child Can Be Released
1.
2.
C. Physician’s Name:
Clinic’s Address:
Clinic’s Phone Number:
D. Is your child’s immunization up to date? Yes ( ) No ( )
Preschool Information
Has your child been separated from you before? Yes ( ) No ( )
If yes, when did this take place? ___________________ For how long? ________________
Are there currently (or been recently) any family related or personal circumstances that may be affecting your child? (eg. death, change of address, parental separation/divorce, other stresses)
Does your child like to play with other children? Yes( ) No( )
Describe the role your child takes when playing with other children. (Eg. leader, follower) _______________________________
What type of discipline is used in your home? ___________________________________________
Does your child use any special or unique forms of communication to express him/herself? (eg. sign language, special words, etc) ________________________________________________________________
What are your expectations of this program?________________________________
Does your child have any pets?___________________________________________
Is there anything else you think we should know about your child?________________
Please attach a letter confirming the mild/moderate need of your child. This letter can be obtained from the following sources: -Your physician, the Health Unit, Children C.A.R.E. Center, Social Worker, Speech Therapist