Copperfield

Preschool Inc
Unit 119, 15566 McIvor Blvd SE, Calgary, T2Z 4Y2
Phone (403) 668 4297
E-mail preschoolinfo@copperfieldpreschool.ca

REGISTRATION FORM 2013/2014

STUDENT INFORMATION
Students Name ____________________ Boy / Girl Date of Birth ______________
Address _______________________________________________________________
City ______________Postal Code __________Any separation problems

Yes / No

Does the student speak English as a first language Yes/No?

If no what is the students first spoken language? ______________________________

PROGRAMME INFORMATION
Please circle which programme you wish to register for. Programme runs from
Tuesday September 3rd 2013 (Closed for Labour Day) to Thursday June 26th 2014.
Please refer to the handbook for all dates the preschool is closed all.
Monday/Wednesday/Friday 08.30am 10.45am 4 Year old class $195.00 per month - FULL
Monday/Wednesday 11.00am 1.15pm Mix 3 + 4 Year old class $175.00 per month - FULL
Monday/Wednesday/Friday 1.30pm 3.45pm 4 Year old class $195.00 per month - FULL
Tuesday/Thursday 08.30am 10.45am Mix 3 + 4 Year old class $175.00 per month - FULL
Tuesday/Thursday 11.00am 1.15pm Mix 3 + 4 Year old class $175.00 per month - FULL
Tuesday/Thursday 1.30pm 3.45pm Mix 3+ 4 Year old class $175.00 per month - FULL

All fees are paid in advance by10 post-dated cheques. These cheques will be banked on
the dates specified in the contract every month. No places will be held until contract,
registration form, registration fee and post dated cheques are received.

PARENT INFORMATION
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Mothers name ___________________ Contact number _________________________

Fathers Name ___________________ Contact Number _________________________
Address ________________________________________________________________
City ______________ Postal Code __________E Mail _________________________
E MAIL WILL BE USED FOR ACCEPTANCE LETTERS
Mother Cell _________________________ Work ______________________________
Father Cell _________________________ Work ______________________________

EMERGENCY CONTACT INFORMATION two people other

thanthe childs parents. (All information must be supplied this is a legal
requirement)
Name _______________________ Contact Number ____________________________
Address ________________________________________________________________
Name ______________________ Contact Number _____________________________
Address________________________________________________________________

PARENT AUTHORIZATION FOR PICK UP

Password ______________________________
It is your responsibility not to give other people the password unless they are on
your authorized pick up list and also to keep the pick up authorization list current.
This password is for the students safety. Please note that if a person is not on the
pick up list your child will not be able to go without us contacting you.
Name __________________________________________________________________
Name __________________________________________________________________

STUDENT HEALTH INFORMATION

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Students Alberta Health Care Number (this information is not optional as it may be
required for medical care) _________________________________________________
Has the student got any allergies/illnesses? Yes/No Please note for any epi-pens or
inhalers A MEDICATION FORM MUST also be filled out prior to starting.
If yes what is/are the allergy/illness
________________________________________________________________________
Is the allergy mild_____ Moderate _____ or severe______
Dr or walk in clinic ________________________ Contact Number _______________
Dentists Name ____________________ Contact Number _______________________
Is the student vaccinated Yes/No?
Are the students vaccinations up to date Yes/No?
If the student is vaccinated please supply a photocopy of the students vaccination
record along with the registration form.
Does the student have any disabilities? Yes/No
If yes please explain ______________________________________________________
Does the student have any illness at present? Yes/No
If yes please explain ______________________________________________________

PHOTOGRAPH RELEASE
May we take pictures of your child to display in:The classroom area? Yes/No

On the website? Yes/No

I declare that the information given above is accurate. I agree to notify the preschool
regarding any changes to this information.
I have read the parents handbook and will abide by the policies and procedures within this
documentation

Print Name _______________________________________

Sign Name ________________________________________ Date _________________

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