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Childcare Centre
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Enrollment
Child's Information
Child's Name:
Gender:
Date of Birth:
Desired Start Date:
Address
Street Address/PO Box #:
City/Town:
Province/State:
Postal Code:
Parent/Guardian #1 Information
Name of Parent/Guardian:
Email:
Primary Phone Number:
Work Phone Number (if applicable):
University Status:
Full-time Undergraduate
Part-time Undergraduate
Full-time Graduate
Part-time Graduate
Staff
Faculty
Non-University
Place of Work:
Parent/Guardian #2 Information
Name of Parent/Guardian:
Email:
Primary Phone Number:
Work Phone Number (if applicable):
University Status:
Full-time Undergraduate
Part-time Undergraduate
Full-time Graduate
Part-time Graduate
Staff
Faculty
Non-University
Place of Work:
Program Options
Toddler Centre (2 year olds)
Full-time
Two full-days
Three full-days
Pre-School (3 – 5 year olds):
Full-time
Two full-days
Three full-days
After-School (5 – 12 yrs. old)
5 days/week
3 days/week
2 days/week
Pre-Kindergarten (4 yrs. old):
5 Mornings
3 Mornings
2 Mornings
Summer Program (5-12 yrs. old):
5 days per week
3 days/week
2 days/week
Medical Information
Name of Family Physician:
Address of Family Physician
Does your child have any Allergies?
Yes
No
Please list Allergies
Does your child have any individual considerations where they may require extra support? (e.g. speech, allergies, physical development, cognitive development, dietary, etc.)
Yes
No
Please Specify
I consent to the collection and use of my personal information in this Waitlist Application as described above
Submit
The personal information collected in this waitlist application will only be used by Campus Childcare Inc., for administrative purposes, including assessing and processing the application for enrollment purposes in Campus Childcare Inc. The information will not be disclosed without your consent except as required by law. If you have any questions about this collection and use of your personal information, please contact Tracy Rose, Executive Director, at (709) 864-4728.