Admissions for Pre School Academic Year 2011

First Name A value is required.
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Last Name A value is required.
Date of Birth A value is required. Mother Tongue A value is required.
Place of Birth A value is required.
   
Grade Applying For
Please select a Grade.		 Academic Year
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Last Grade Passed
 Please select a Grade.  
   
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City

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Home
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Email
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Home A value is required.Invalid format. Office Mobile Email
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Outing
I am willing my child A value is required.to go on outside expeditions with the chld care staff.
 
Emergency Treatment
I am willing for my child A value is required. to have medical attention and be taken to the hospital in the case of an emergency, if I/we cannot be reached.
 
 

CHILD HEALTH QUESTIONNAIRE
Child's Provincial Health Care Number: A value is required.Expiry Date: A value is required.
 
In Case of Emergency
Name A value is required. Relationship to child A value is required.
Home Phone
A value is required. 		Work Phone
A value is required.		 Cell
A value is required.		  
 
Physician Information
Name A value is required. Phone A value is required.
Address A value is required.
 
 

IMMUNIZATION RECORD
DPTP-Diptheria, Pertussis (Whooping Cough)
Tetanus (Lockjaw), Polio & Hib
MMR - Measles (red), Mumps, Rubella (German Measles)
1st (2 mo) day/month/year 1st (12-15 mo) day/month/year
2nd (4 mo) day/month/year 2nd (5 year) day/month/year
3rd (6 mo) day/month/year  
4th (8 mo) day/month/year  
  OTHER (optional)
DPTP (booster) 4-6 year
 Varicella: (Chicken Pox Vaccine)
day/month/year
   
Hepatitis "B" 3 Doses
1st Dose
2nd Dose
3rd Dose
 
Dentist and/or clinic Name Phone
Address
 
 
Background Information
Please list siblings, adults, pets, etc. that presently live in the home.
 
Has your child been in a child care arrangement before? Yes No
Please describe the experience
 
 

Health & Developmental History
 
Describe your child's general health
 
Is your child taking any medication? What medication is it and what is it for?
 
Please list below any allergies to foods, medications or contact allergies.
 
Is the allergy severe enough to require medication or emergency treatment?



 
If yes to the above, please describe and detail any medications required
 
Has your child eaten peanut butter at home?



 
Please describe any other diet restrictions (culturual, religious)
 
 

Behaviour Patterns & Habits
 
Describe your child's behaviour and habits (e.g temperament, energy level)
 
We would appreciate your views on guiding your child's behaviour and setting limits
 
Is there anything else you would like to tell us about your child to help us to provide good care?
 

* A deposit of $150/family is payable before June 30, 2008, in order to secure a place for your child at the Academy for the next Academic Year 2008-2009. A registration fee $150.00 is required for all new families payable upon admission.
 

I, Please enter your name. the under signed, parent/guardian who is responsible for the above named student. I understand, accept and agree to abide by the Academy regulations, and rules.  I will also help my child to understand and abide by these rules.
 

I also agree and take the full responsibility for the payment of the tuition fees for the above named student on time as agreed and scheduled between MMA and myself.  I do understand that delaying the payment of the tuition fees may cause me to pay late payment fees and that any failure of paying the full due amount may result in the suspension or dismissal of the above named student. I the undersigned agree that the above information is accurate to the best of my ability.
 
You must agree to the terms. By clicking on this check box I understand and agree to all terms and conditions.
Date Submitted 04-09-2010