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KidZinc Child Registration

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Does your child have any non-allergy dietary restrictions?YesNo

If yes, please describe:

Does your child have any developmental delays?YesNo

If yes, please describe:

Does your child have behavioural, social, mental health needs?YesNo

If yes, please describe:

Add 2nd child (Yes/No)

YesNo

Child Full Name:
Birthdate:
Age September 2022:
Gender:
Primary Home Address:
City:
Province:
Postal Code
Home Language:
School:
Grade September 2022:
Type of Care Needed:

Custody Order?YesNo
Protection Order?YesNo
Immunization Up to Date? YesNo
Does your child require medication while at KidZinc programs(ie. Epipen, inahler)?YesNo
Medication & Reason:
Second Medication & Reason:
If yes, program staff will provide you with a medication authorization form.
Does your child have allergies?YesNoType: Severity (low,medium,high): Symptoms: Treatment:
Does your child have a second allergy?YesNo
Type: Severity (low,medium,high): Symptoms: Treatment:

Does your child take any regular medication outside of KidZinc?YesNoName of Medication:Reason for Medication:
Does you child take a second regular medication? YesNo Name of Medication:Reason for Medication:

Does your child have any non-allergy dietary restrictions?YesNo

If yes, please describe:

Does your child have any developmental delays?YesNo

If yes, please describe:

Does your child have behavioural, social, mental health needs?YesNo

If yes, please describe:

Add 3rd child (Yes/No)

YesNo

Child Full Name:
Birthdate:
Age September 2022:
Gender:
Primary Home Address:
City:
Province:
Postal Code
Home Language:
School:Grade September 2022:
Type of Care Needed:
Custody Order?YesNo
Protection Order?YesNo
Immunization Up to Date? YesNo
Does your child require medication while at KidZinc programs(ie. Epipen, inahler)?YesNo
Medication:
Second Medication & Reason:
If yes, program staff will provide you with a medication authorization form.
Does your child have allergies?YesNoType: Severity (low,medium,high): Symptoms: Treatment:
Does your child have a second allergy?YesNo
Type: Severity (low,medium,high): Symptoms: Treatment:

Does your child take any regular medication outside of KidZinc?YesNoName of Medication:Reason for Medication:
Does you child take a second regular medication? YesNo Name of Medication:Reason for Medication:

Does your child have any non-allergy dietary restrictions?YesNo

If yes, please describe:

Does your child have any developmental delays?YesNo

If yes, please describe:

Does your child have behavioural, social, mental health needs?YesNo

If yes, please describe:

Emergency Contact #1 (Required)

(Must be a person other than a parent/guardian who lives in Calgary or surrounding area. This person is authorized to pick the child up from the program in emergency situations only and only when a parent/guardian cannot be reached.)

Full Name:
Relationship to child:
Address:
City:
Province:
Postal Code:
Home Phone:
Cell Phone:
Work Phone:

Emergency Contact #2

(Other than parent/guardian) YesNo

Full Name:
Relationship to child:
Address:
City:
Province:
Postal Code:
Home Phone:
Cell Phone:
Work Phone:

Authorized Alternate Pick-Up Contact #1

(People, other than parent/guardians who are permitted to pick-up the child(ren) from the program. Must be over the age of 16, unless they are a sibling of the registered child)

Full Name:
Relationship to child:
Phone Number:
Can pick up:AnytimeWith Prior Consent

Authorized Alternate Pick-Up Contact #2

(People, other than parent/guardians who are permitted to pick-up the child(ren) from the program. Must be over the age of 16, unless they are a sibling of the registered child) YesNo

Full Name:
Relationship to child:
Phone Number:
Can pick up:AnytimeWith Prior Consent

Authorized Alternate Pick-Up Contact #3

(People, other than parent/guardians who are permitted to pick-up the child(ren) from the program. Must be over the age of 16, unless they are a sibling of the registered child) YesNo

Full Name:
Relationship to child:
Phone Number:
Can pick up:AnytimeWith Prior Consent

GENERAL CONSENT

(Each of the following are REQUIRED to submit this form)

I have read, understand, and agree to all the policies outlined in the KidZinc Family Handbook.
I consent for my child(ren) to participate in the daily, regular activities within the KidZinc program, including indoor and outdoor play.
I consent for first aid to be administered to my child(ren) should he/she/they become injured or ill while in the care of KidZinc.
I consent for my child(ren) to receive emergency health care should he/she suffer an injury or serious illness while in the care of KidZinc. This includes transportation to an emergency health facility by KidZinc vehicle or ambulance.
I consent for my child(ren) to be transported by KidZinc vehicle between the KidZinc program and school, where required. Children are transported in accordance with Alberta Transportation regulations.
I consent for my child(ren) to participate in community out-trips within walking distance of the program location without advance notice, such as to nearby playgrounds, neighbourhood walks, or another program location. Staff are required to post notices on program doors informing parents/guardians of their location.
I consent to informal sharing of information between KidZinc and staff at my child(ren)’s school. Information shared may include, but is not limited to, child attendance, transportation, health, or behavior (ie. Child went home sick from school).
I agree to pay monthly childcare fees in full and any additional fees as required as per the KidZinc Fee Schedule.
I understand I must provide 30 days written notice of cancellation of care during the school year or I will be charged the full month’s fee. To cancel for September, I understand I must provide written notice no later than June 1 to avoid being charged a full month’s fee for September.
By entering your name and clicking Agree below, you are agreeing to all terms and conditions as outlined in the KidZinc Family Handbook.

AGREE (REQUIRED)

MEDIA RELEASE

Check all that apply:

I give consent for my child’s artwork or writing to be used in KidZinc newsletters, posters, brochures or other written marketing materials.
I give consent for my child’s artwork or writing to be used on the KidZinc website.
I give consent for my child’s artwork or writing to be used on KidZinc social media accounts (Facebook, Instagram, Twitter)
I give consent for my child’s photo to be posted in their specific KidZinc program (i.e. Birthday wall or award recognition).
I give consent for my child’s photo/video to be used in KidZinc newsletters, posters, brochures or other written marketing materials.
I give consent for my child’s photo/video to be used on the KidZinc website.
I give consent for my child’s photo/video to be used on KidZinc social media accounts (Facebook, Instagram, Twitter)

OR

I do not give any media release consent for my child.
By entering your name and clicking Agree below, you are providing KidZinc with media release consent under the conditions noted above.

AGREE (REQUIRED)

PARENT VOLUNTEER COMMITMENT

Check all that apply.

KidZinc recognizes the importance of family involvement in the success of its programs. Parents/guardians will be presented with a variety of volunteer opportunities and are encouraged to volunteer at least once per school year.

Please indicate below which volunteer areas are of interest to you.

Present a workshop to children in the program based on personal skill set. (ie. karate instruction, art instruction, sports instruction)Area of expertise:

Provide instruction and support to organization based on personal skill set. (ie. IT support, marketing support, legal advice)Area of expertise:

Participate in community projects to help raise the profile of KidZinc (community clean up, skating rink maintenance, community gardens).
Participate directly in the program for special events.
Casino Fundraiser.
Board of Directors/Board Committee (Locations, Fund Development, Strategic Planning).

In some circumstances, volunteers may be required to provide proof of a successful Police Security Clearance before volunteering.You will be contacted by program staff regarding volunteer opportunities.

AUTHORIZATION

I understand that each check box within this document constitutes electronic consent in lieu of an original signature on paper.
I confirm that, to the best of my knowledge, all information contained in this document is accurate.
I agree to all terms and conditions of service as outlined in the KidZinc Family Handbook.

** Registration will NOT be submitted if any required fields have not completed **

** Please note , any fields that are still required will be outlined in RED, ensure you scroll up the form to view any missing fields like the examples below.**