Registration Form - DJN - Jane Norman College

Registration Form DJN

Step 1 of 8

Child
Name of Child*
First Middle Last
Age*
Date of Birth*
MM slash DD slash YYYY
Home Address*
Street Address Address Line 2 City Province Postal Code
Mailing Address
- Mailing address is different than home address
Mailing Address
Street Address Address Line 2 City Province Postal Code
Parent / Guardian
Name of Parent / Guardian*
First Middle Last
Home Phone for Parent / Guardian
Cell Phone for Parent / Guardian
Work Phone for Parent / Guardian
Email for Parent / Guardian*
Home Address of Parent / Guardian*
Street Address Address Line 2 City Province Postal Code
Name of Parent / Guardian #2
First Middle Last
Home Phone for Parent / Guardian #2
Cell Phone for Parent / Guardian #2
Work Phone for Parent / Guardian #2
Email for Parent / Guardian #2
Home Address of Parent / Guardian #2
Street Address Address Line 2 City Province Postal Code
Emergency Contact
In the case of an emergency or illness and if neither parent can not be reached, please list the name and phone number of an alternative contact person.
Emergency Contact Name*
Emergency Contact Phone Number*
People authorized to pick up your child from the program*
Please include: Name, phone number
Please identify any additional supports your child may require for meaningful participation in our program.*
All children are welcome at the Dr. Jane Norman Child Study Centre. Please identify any additional supports your child may require for meaningful participation in our program.

This may also include any supports identified by other professionals ie: speech and language, developmental interventionist’s etc.

Please describe additional supports
Will your family be receiving a child care subsidy through the Department of Education and Early Childhood Development?*
- Yes
- No

Child’s Health Questionnaire
Dr Jane Norman Child Study Centre: Child’s Health Questionnaire
Name of Child*
Health Card Number*
Health Card Expiry Date*
Emergency Contact
Emergency Contact Name*
First Last
Relationship*
Emergency Contact Phone*
Emergency Contact Alternate Phone
Physician and/or Clinic
Name*
Phone*
Address*
Street Address Address Line 2 City Province Postal Code
Dentist and/or Clinic
Name*
Phone*
Address*
Street Address Address Line 2 City Province Postal Code
Immunization Records
**This form must have an up to date copy of your child’s immunization record attached.**
File Upload
Drop files here or

Max. file size: 100 MB.

Emergency Medical Consent Form
Dr Jane Norman Child Study Centre: Emergency Medical Consent Form
Though all program staff are trained in emergency first aid and CPR and will administer any necessary treatment as required, should a child have an accident during the program hours, the program staff will assess the situation and follow the procedures below:
- if the accident requires medical attention, the program staff will contact the parent immediately for instruction
- if the parent is unavailable, the program staff will contact the alternate emergency contact for instruction
- if neither the parent nor the alternate emergency contact is available, the program staff will call for emergency transport (as program staff may not transport any child in their personal vehicles)
- if the accident is identified as needing immediate assistance, emergency transport will be called first and then the parent or alternate contact will be called.
Program staff may not be able to ride with a child in the emergency transport vehicle but will travel to the hospital in the event that the parent or emergency contact cannot be reached.
Name
First Last
Consent*
I hereby grant permission for the program staff to take the above listed steps in the case of an accident. This authorization agreement will stand from this day until the termination of the child’s attendance in the program.

Jane Norman College Programs and Dr Jane Norman Child Study Centre Permission Form
Jane Norman College offers diplomas in Early Childhood Education, Inclusion and Intervention, and Youth Work, as well as a certificate in Public School Program Assistance (EA). During the school year the college’s students complete their practicum (practical work experience) and course work at a number of schools, daycares, and child related programs across Nova Scotia but predominantly in the Truro area. The Dr Jane Norman Child Study Centre is a lab school for Jane Norman College meaning that during a child’s time st the Dr Jane Norman Child Study Centre there may be students from Jane Norman College at the program for short periods of time to complete course work or for an extended stay during practicum. Prior to any Jane Norman College student involvement with outside programs they have criminal records and child abuse registry checks lodged with the college’s Student Services Division. In addition, a Practicum Coordinator prepares students for their interactions with programs, other professionals and the children that are being served.

These practicum opportunities and observation times are an invaluable part of the student’s education and training. To this end we ask that parents grant permission for their child to be observed and potentially photographed during the program. Should a parent not want their child to be part of the college’s practicum and observation process please indicate on the form below.
Name of Child*
First Last
Name of Parent / Guardian*
First Last
Consent*
I hereby GRANT permission:
- To allow students of the Jane Norman College to observe my child while completing their studies toward a diploma or certificate in Human Services at the college.
- To allow my child to have his or her picture taken and/or be videotaped for instructional and promotional purposes.
- To allow community partners to take occasional pictures of my child (ex: visit to the police station or Truro Daily News).
This authorization agreement will stand from this day until the termination of the child’s attendance at the Centre, unless specific notification in writing is given to the Director of the Centre to end the authorization.

Dr. Jane Norman Child Study Centre - Facebook Form
We have a Facebook group for the Dr. Jane Norman Child Study Centre. This is a closed group, which means that pictures, posts, comments will only be visible to members of the group. We are keeping members limited to parents and family members of children who are currently enrolled in the program. We try to post pictures daily with captions, so that you know what our children are up to. This is also a great means of sharing our current emergent curriculum topics.

The Jane Norman College also has a Facebook page which it operates. This is an open page and used frequently by former students, current students, perspective students, faculty, staff and parents. Periodically we add photos of the children from the Child Study Centre to this site.
Name of Child*
First Last
Name of Parent / Guardian*
First Last
Consent
- I give permission for my child to have his/her picture taken and posted on Facebook.
- I do not give permission for my child to have his/her picture taken and posted on Facebook.

Dr. Jane Norman Child Study Centre - Sunscreen Form
Licensing has requested that parents sign a permission form allowing sunscreen to be applied to their child. Please read the form below and sign accordingly.
Name of Child*
First Last
Name of Parent / Guardian*
First Last
Please specify below if your child has any allergies or sensitivities to sunscreen.
Consent
- I give permission for sunscreen to be applied to my child
- I do not give permission for sunscreen to be applied to my child
Authorization Form
-I acknowledge that I have received and read the Dr. Jane Norman Child Study Centre Handbook.

-I hereby grant permission for my child to use all of the play equipment and participate in all aspects of the program offered at the Dr. Jane Norman Child Study Centre.

-I hereby grant permission for my child to leave the Dr. Jane Norman Child Study Centre premises under the supervision of a staff member for neighbourhood walks or local outings.

-I acknowledge that I have completed the following forms and submitted them to the Dr. Jane Norman Child Study Centre:
- Registration Form
- Health Questionnaire (complete with immunization record)
- Emergency Medical Consent Form
- Permission Form
- Facebook Form
- Authorization Form
-I hereby acknowledge that I have read and I agree to the following policies found in the Dr. Jane Norman Child Study Centre handbook:
- Health and Nutrition Policy
- Behaviour Management Policy
- Dismissal Policy
- Communication Policy
- Duty to Report Suspected Abuse Policy
Consent*
I agree and acknowledge the above has been completed
Name of Child*
First Last
Name of Parent / Guardian*
First Last
CAPTCHA

Registration Form DJN

Step 1 of 8

Child

Parent / Guardian

Emergency Contact

Child’s Health Questionnaire

Emergency Contact

Physician and/or Clinic

Dentist and/or Clinic

Immunization Records

Background Information

Health and Developmental History

Diet

Behaviour Patterns and Habits

Emergency Medical Consent Form

Jane Norman College Programs and Dr Jane Norman Child Study Centre Permission Form

Dr. Jane Norman Child Study Centre - Facebook Form

Dr. Jane Norman Child Study Centre - Sunscreen Form

Authorization Form