Where education, care, and play go hand in hand
(587) 351-3314
glenmoredaycare123@gmail.com
Fill out the form below to enroll your child at Glenmore Daycare
Child Information
Surname *
First Name *
Health Care Number
Age *
Date of Birth *
Care Required Per Week *
Parent 1
Surname *
First Name *
Address *
Phone Number
Work Phone
Place of Work
Occupation
Marital Status
Parent 2
Surname
First Name
Address
Phone Number
Work Phone
Place of Work
Occupation
Marital Status
Other than parent(s), who has permission to pick-up the child?
Name
Phone Number
Work Phone
Relationship
Child's Health Information
Birth Weight
Family Doctors Name
Date of most recent physical exam
When was your child last immunized?
Is your child's immunization up to date?
Does your child have any special needs? If yes please specify.
Does your child have any allergies including drug reactions? If yes, please specify:
Does your child take any medication? If yes please specify:
Which of the following conditions are applicable to your child?
Consent/Agreement

1. Photo Release: I give (please select one) permission for photographs of my child (ren) to be displayed within the Daycare

2. Development Screening: I give permission of a developmental screening tool to be used with my child while in care within daycare. This will aid in my child receiving the best care possible.
3. Medical Aid/Assistance: In case of an emergency, I authorize the qualified staff of Glenmore Daycare to take any steps necessary for the benefit of my child.
4. Transportation: I understand that time to time Glenmore Daycare may need to transport my child by walking/yellow school bus/ public transit to field trips and hereby authorize the staff to do so.
5. Field Trips: I understand that as a part of the program at the center my child will visit various community areas/amusement centers/ Library.I have read and understood the conditions provided above. By sending my child to Glenmore Daycare, I am agreeing to the conditions and consent to all actions taken by the staff for the benefit of my child.

Signature / Name of Parent *
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