Wee Watch Enriched Home Child Care
APPLICATION FOR ENROLLMENT

PARENTS/GUARDIANS - PERSONAL

Parent/Guardian :
Address :

City :
Province :
Postal Code :
Home Phone :
Company :
Company Address :

Company City :
Company Province :
Company Country :
Company Postal Code :
Occupation :
Business Phone :
Cell/Pager :
Parent/Guardian :
Address :

City :
Province :
Postal Code :
Home Phone :
Company :
Company Address :

Company City :
Company Province :
Company Country :
Company Postal Code :
Occupation :
Business Phone :
Cell/Pager :


PARENTS/GUARDIANS - GENERAL
Custody Arrangements (if applicable) :
Languages Spoken at home :
Date Day Care Required :
Do you or your spouse smoke?
Yes       No      
Do you have pets?
Yes       No      
If yes, what type?

CHILD - PERSONAL
(For more than one child, please use a separate form)
Name :
Gender :
Birthdate :
Please outline your child's daily routine :
Please describe your child's general personality (likes, dislikes, etc.) :
Names and Ages of Siblings :

CHILD - MEDICAL
Any known allergies, health, or medical problems?
Yes       No      
If yes, please describe :
Does your child require any special foods or liquids or any special diet?
Yes       No      
If yes, please describe :
Physician's Name :
Physician's Address :

Physician's City :
Physician's Province :
Physician's Country :
Physician's Postal Code :
Physician's Phone Number :

PROVIDER
What type of a Provider are you looking for?
What type of home would you like your child to be placed in?

EMERGENCY CONTACTS
Persons to contact in emergency if parents cannot be reached, and to whom child may be released

Name :
Phone Number :
Relationship :
Name :
Phone Number :
Relationship :
Name :
Phone Number :
Relationship :
Name :
Phone Number :
Relationship :


SCHEDULE & LOCATION
Hours of Work :
Days of Work :
I will need day care for the following days & hours :
Closest intersection to work :
Closest intersection to home :
Child's School :
Provider locations (furthest acceptable boundaries) :

GENERAL COMMENTS
Please outline any additional comments or requirements regarding day care for your child :
Where did you hear about Wee Watch?
What is your name?
Please provide your email address :

The agency will contact you to discuss your needs, answer your questions, and advise you of the registration fee.