Full Name
Relationship to Child
Address
City
Province
Postal Code
Phone Number (Primary)
Phone Number (Secondary)
Email Address
Employment/School Name
Address of Employment/School
Phone Number of Employment/School
Work/School Schedule
Phone Number
Child 1 Full Name
Child 1 Date of Birth (DD/MM/YYYY)
Child 1 Gender
Child 1 School
Child 1 Grade
Child 2 Full Name
Child 2 Date of Birth (DD/MM/YYYY)
Child 2 Gender
Child 2 School
Child 2 Grade
Child 3 Full Name
Child 3 Date of Birth (DD/MM/YYYY)
Child 3 Gender
Child 3 School
Child 3 Grade
Child 4 Full Name
Child 4 Date of Birth (DD/MM/YYYY)
Child 4 Gender
Child 4 School
Child 4 Grade
Preferred Start Date
Days Care is NeededMondayTuesdayWednesdayThursdayFridayOther
Other (Specify if checked)
Drop-off Time
Pick-up Time
Authorized Pick-Up 1 Full Name
Authorized Pick-Up 1 Phone Number
Authorized Pick-Up 2 Full Name
Authorized Pick-Up 2 Phone Number
By signing below, I confirm that the information provided is accurate and complete to the best of my knowledge. I agree to abide by the policies and procedures of The Learning Lounge and understand that my child’s placement is contingent upon meeting all requirements.I agree
Parent/Guardian Signature
Home Visitor Signature
Date Received
Reviewed By
Placement ConfirmedYesNo
Notes
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