CHILD REGISTRATION FORM

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CHILD REGISTRATION FORM

General Information

Child #1

First Name

Middle Name

Last Name

Age

Date of Birth

Gender

Medical Information

Doctor's Name

Doctor's Telephone #

Allergies, disabilities, etc.

Child #2

First Name

Middle Name

Last Name

Age

Date of Birth

Gender

Medical Information

Doctor's Name

Doctor's Telephone #

Allergies, disabilities, etc.

Relationship

What is your relationship to the child(ren) you are registering?

Emergency Contact Information

Emergency Contact Person name

Relation to Child

Telephone number where person can be reached during program hours

Emergency Procedure

Emergency Procedure:

In the event of an emergency, when the emergency contact person (listed above) cannot be reached, I authorize my child(ren) to be transported to a hospital by ambulance and required to ensure proper medical treatment. I hold Delta Family Resource Centre and its staff harmless for any accident or injury to my child(ren). Delta Family Resource Centre will take all reasonable attempts to ensure the health and safety of my child(ren) while in attendance

Do you agree?

Yes

Release Authorization

Release Authorization:

Child(ren) attending DFRC Programs will not be released to anyone other than the parent/guardian unless authorized. I authorize the following person to pick up my children.

Name of person to be authorized

Telephone

Photo Consent

Yes — I hereby consent to taking and use of photographs of my child for promotional purposes.

No — I don't consent to taking and use of photographs of my child for promotional purposes.

Declaration

I hereby agree that all the information on this page (Photo Consent, Release Authorization and Emergency Contact/Emergency Procedure) are accurate.