Registration Form - JNC ASP - Jane Norman College

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
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 Jane Norman College After School Program. 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

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
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*
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.

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
JNC After School Program
Name of Child*
First Last
Name of Parent / Guardian*
First Last
Consent
I have read all of the policies in the Jane Norman College After School Program Handbook and agree to abide by these policies.
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Child