Registration - Learn & Play

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Family

Choose Program *

Choose Frequency

Faily Name *

First Parent

Relation To Child *

Name *

First

Last

Cell Phone Number *

Home Phone Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Work Name *

Work Phone *

Work Address *

Birth Date *

Email *

Second Parent

Relation To Child *

Name *

First

Last

Cell Phone *

Home Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Work Name *

Work Phone *

Work Address *

Birth Date *

Email *

First Child

Given Name *

First

Last

Goes By *

Birth Date *

Sex *

Living Arrangements

Child Lives With

Mother
Father
Other

Is There A Custody Agreement *

Yes
No

Enrollment

Desired Starting date *

Room *

Frecuency *

Medical Conditions

Health Care *

Physician's Name *

Physician's Number *

Diet Restrictions *

Allergies *

Other Medical Concerns

Is Your Child's Immunization Up to Date *

Yes
No

Does your child receive medication on an ongoing basis? *

Yes
No

Subsidy *

Subsidy Is Approved
I've Applied For Subsidy
I'll Apply For Subsidy
I Need Help To Apply For Subsidy
I Do Not Plan To Apply for Subsidy

Second Child

Do You Have A Second Child *

Yes (Fill The Below Form)
No (You may Go to The Next Page)

Name

First

Last

Birth Date

Sex

Child Lives With

Mother
Father
Other

Is There A Custody Agreement ?

Yes
no

Enrollment

Desired Start Date

Room

Frequency

Medical

Healthcare

Physician's Name *

Physician's Phone

Diet restriction

Allergies

Other Medical Concerns

Is Your Child's Immunization Is Up To Date

yes
No

Does your child receive medication on an ongoing basis?

yes
No

Subsidy (copy) *

Subsidy Is Approved
I've Applied For Subsidy
I'll Apply For Subsidy
I Need Help To Apply For Subsidy
I Do Not Plan To Apply for Subsidy

Emergency Contact

Relation To Child *

Name *

First

Last

Cell Phone *

Home Phone

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Authorized For Pick Up *

Yes
No

How Did You First Here About Us *

Print Directory
Alberta Government Website
Web Search
Word of Mouth (referral)
Drive by (saw the signs)
Other

I am Not A Robot

I am Not A Robot

Fill This To Register

Family

Choose Program *

Choose Frequency

Faily Name *

First Parent

Relation To Child *

Name *

First

Last

Cell Phone Number *

Home Phone Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Work Name *

Work Phone *

Work Address *

Birth Date *

Email *

Second Parent

Relation To Child *

Name *

First

Last

Cell Phone *

Home Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Work Name *

Work Phone *

Work Address *

Birth Date *

Email *

First Child

Given Name *

First

Last

Goes By *

Birth Date *

Sex *

Living Arrangements

Child Lives With

Mother
Father
Other

Is There A Custody Agreement *

Yes
No

Enrollment

Desired Starting date *

Room *

Frecuency *

Medical Conditions

Health Care *

Physician's Name *

Physician's Number *

Diet Restrictions *

Allergies *

Other Medical Concerns

Is Your Child's Immunization Up to Date *

Yes
No

Does your child receive medication on an ongoing basis? *

Yes
No

Subsidy *

Subsidy Is Approved
I've Applied For Subsidy
I'll Apply For Subsidy
I Need Help To Apply For Subsidy
I Do Not Plan To Apply for Subsidy

Second Child

Do You Have A Second Child *

Yes (Fill The Below Form)
No (You may Go to The Next Page)

Name

First

Last

Birth Date

Sex

Child Lives With

Mother
Father
Other

Is There A Custody Agreement ?

Yes
no

Enrollment

Desired Start Date

Room

Frequency

Medical

Healthcare

Physician's Name *

Physician's Phone

Diet restriction

Allergies

Other Medical Concerns

Is Your Child's Immunization Is Up To Date

yes
No

Does your child receive medication on an ongoing basis?

yes
No

Subsidy (copy) *

Subsidy Is Approved
I've Applied For Subsidy
I'll Apply For Subsidy
I Need Help To Apply For Subsidy
I Do Not Plan To Apply for Subsidy

Emergency Contact

Relation To Child *

Name *

First

Last

Cell Phone *

Home Phone

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Authorized For Pick Up *

Yes
No

How Did You First Here About Us *

Print Directory
Alberta Government Website
Web Search
Word of Mouth (referral)
Drive by (saw the signs)
Other

I am Not A Robot

I am Not A Robot