Cribs To Crayons: Online Application Form

Once submitted, we will contact you within 7 days!

Personal Information

Full Name of Child

Nickname (if used)

Child's Date of Birth

YYYY

Child's Gender

Child's Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Home Phone Number

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Parent/Guardian Information

Mother's Name

Mother's Cell Number

(###)

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Mother's Home Address (if different than above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Work Number

(###)

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Mother's Work Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Hours of Work

Father's Name

Father's Cell Number

(###)

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Father's Home Address (if different than above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Work Number

(###)

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Father's Work Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Hours of Work

Guardian's Name (if necessary)

Guardian's Cell Number

Guardian's Home Address (if different than above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian's Work Number

Guardian's Work Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian's Hours of Work

Person(s) Authorized to Pick Up Child

Name of Authorized Person 1

Relationship To Child

Phone Number

Name of Authorized Person 2

Relationship To Child

Phone Number

Name of Authorized Person 3

Relationship To Child

Phone Number

(###)

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Emergency Health Information

Care Card Number

Family Doctor's Name

Family Doctor's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Family Doctor's Phone Number

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Health Information

Medication(s) and reasons for taking them (please list):

Allergy/allergies and treatments (please list):

Accident(s), illness(es), or operations your child has had, including date:

Describe any concerns you may have regarding your child's development (i.e. behaviour, vision, hearing, speech, language, etc.):

Eating and Nutrition

Describe any particular eating patterns:

Are there any religious or ethnic restrictions with respect to your child's diet?

Sleeping Habits

Time of regular nap:

Length of regular nap:

Time of waking:

Is your child a deep sleeper or does (s)he awaken easily?

Toileting

Is your child toilet trained?

What special word does your child use for urination and bowel movements?

Play Group and Experiences

What are your child's favourite toys?

What types of play activities does your child enjoy?

Emotional

Does your child have any particular fears? Please describe:

What suggestions do you have that might help staff make your child's transition into the program easier?

Family and General Household Information

Please list the names of the significant people in your child's life and the relationship to the child (e.g. siblings, grandparents, pets, etc.):

Please describe the guidance and discipline methods used at home:

Primary language spoken at home:

Other languages spoken at home:

Application Contact Information

Contact Name

Contact Email Address

Contact Phone Number

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