Fernie School Aged Care Registration Form

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Medical Notes

Child's Details

First Name *

Last Name *

Date of Birth *(DD/MM/YYYY)

Gender *

Hair Colour *

Eye Colour *

Height *

Weight *

School *

Grade *

Current Date

Start Date(Office Use Only)

End Date(Office Use Only)

Age

Parent Details

Mother's Name *

Phone - Home

Father's Name

Phone - Home

Mom's Email *

Phone - Cell

Dad's Email

Phone - Cell

Address *

Phone - Work

Address

Phone - Work

Emergency Contacts

Contact #1

Contact #2

Name *(In case parents can not be reached)

Name

Phone - Cell *

Phone - Cell

Contact in an emergency? *

YesNo

Contact in an emergency?

YesNo

Please list other people who are authorized to pick up your child.

Name

Phone - Cell

Are there specific individuals who are not allowed access to your child? *

YesNo

Please provide details *

Please provide a copy of relevant court orders regarding parental access. Documents can be uploaded or brought in person to the center manager.

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Medical Information

Doctor's Name *

Phone Number *

BC Care Card # *

Immunization Status *

Immunizations are up to dateChose not to immunize

Immunization records can be uploaded or brought to the center manager in person

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Does your child have any allergies or food sensitivities? *

YesNo

Please list all allergies and sensitivities *

What reaction do they have when exposed to the allergen? *

List any medication they carry for this allergy

Does your child have any medical conditions? *

YesNo

Please provide more details *

I am interested in registering for: *

After School careMarch Break CampSummer CampNo School Fridays

Select all that apply

Permissions

I have read the Fernie School Aged Care parent handbook. I agree to the FSAC guidelines, policies, and procedures outlined in the parent handbook.
Handbook can be found here: https://tinyurl.com/ypbz7v54

I give permission for Fernie School Aged Care to call an ambulance in an emergency. *

Yes

I give permission for Fernie School Aged Care to take pictures of my child for use in the classroom, social media, and websites. *

YesNo

I give permission for Fernie School Aged Care to take my child on field trips, walks, hikes around Fernie *

Yes

Licencing requires us to have a colour photo on file of your child. Photos can be uploaded now or submitted in person at Fernie School Aged Care.

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Sign here *

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