1- Child’s General Information

Child’s Full Name: ........................................................................................        Sex:        O Male                 O Female

Date of Birth: ................. / ………… / ………………….                             Place of Birth: ………………………………………………….

Citizenship: ……………………………………………….

Mother’s Maiden Name: ……………………………………………….            Mother’s Citizenship: ………………………………………….

Child’s Home Address:

County: ........................................................................

Area: ...........................................................................

Street: .........................................................................

Phone: ..............................................................................

Has the child attended any daycare before?   O Yes            O No

If yes, when and where? ...............................................................................................................................................

Parent’s information:

Father information:

Job: .......................................................

Work Phone Number: ........................................................

Mobile Phone Number: ........................................................

Email: ......................................................................

Mother information:

Job: .......................................................

Work Phone Number: ........................................................

Mobile Phone Number: ........................................................

Email: ......................................................................

Does a special case exists with parents?  O Yes            O No

If yes, explain? ..............................................................................................................................................

In case of divorce, who has custody of the child, please specify: ...................................................

Does a special health issue exist in the house?  O Yes            O No

If yes, explain? ..............................................................................................................................................

I am the undersigned bellow, Mr/Mrs: ............................................... the legal guardian of:............................................

Hereby declare

That all information stated above in this form are true, correct and whole

And I promise to abide by the laws of Canadian Daycare and deliver all requested documents.

Signature:................................................. Date:.................................