Preschool Application Form

Program

Start Date

Tuition is payable in advance by the first of each month.

Program - Monthly Fees

These fees include a reduction of approximately 20% resulting from our participation in the BC Government Child Care Fee Reduction Initiative

Please Check

2 Days, 4 Hrs/Day ($196) 2 Days, 5 Hrs/Day ($245) 3 Days,4 Hrs/Day ($256) 3 Days,5 Hrs/Day ($320) 5 Days,4 Hrs/Day ($391) 5 Days,5 Hrs/Day ($489)

Please note:
2-day/week attendance is on Tuesdays & Thursdays.
3-day/week attendance is on Mondays, Wednesdays & Fridays.

If you have any questions please don't hesitate to contact us.

Child Information

Name (First and Last)

Known As:

Address

Date of Birth

Gender

First Language

Second Language

Does your child have special needs?

Parent/Guardian Information - 1

Name (First & Last)

Relationship to Child

Address( if different than the child's)

Primary Phone #

Employer

Work Phone

This address will receive a confirmation email

I want to receive monthly emails

Yes No

Facebook Profile

Parent/Guardian Information - 2

Name (First & Last)

Relationship to Child

Address ( if different than the child's)

Primary Phone

Employer

Work Phone

Facebook Profile

Emergency Health Information

RE Card ( MSP ) Number

Family Doctor

Phone

Please list all allergies and/or other medical conditions

Is your child immunized?

Yes No

Please inform us of any special information that will assist the teachers in making a smooth transition for your child into our classroom

Person(s) authorized to pick up child and emergency contacts

Enrolled children will not be released to anyone other than the individuals listed below. I understand and agree that the two individuals named (who do not reside at the same address) may be contacted in case of an emergency and are authorized to pick up my child from preschool in my absence. These individuals may also be contacted if a parent/guardian cannot be reached and immediate assistance is required.

Name (First & Last)

Relationship

Phone

Address

Name (First & Last)

Relationship

Phone

Address

Is there anyone who is NOT allowed to have access to your child?

Name

If there is custody agreement, please give us details and attach a copy

Emergency Consent

Should the staff at Chipmunk Achievers be unable to contact a parent/guardian or emergency contact and my child requires immediate medical attention, I authorize my child to be transported by ambulance to the nearest emergency centre and consent to any necessary medical treatment. I understand that staff will continue to make every reasonable effort to contact a parent/guardian or emergency contact.

Date Signed

Print name of parent/guardian

Other Information

Has your child previously attended Preschool or Daycare? If yes, where?

Names and ages of your child's siblings ( if applicable)

Church Affliction (as applicable)

Release of Information Permission

In accordance with the Freedom of Information and Protection of Privacy Act, Chipmunk Achievers requires consent to use personal information for the purposes unrelated to the educational program.

1. There are occasions when we would like to contact person(s) to consult them directly about school issues or meetings, or to plan school-related activities. To contact you for these purposes, we need consent for the disclosure of your name, home address and phone number to staff members responsible for organizing these activities.

Yes I give consent for the release of my home address and phone number for purposes consistent with the above No I do not permit the release of my home address and phone number for purposes consistent with the aboveOption

2. It is a tradition of Chipmunk Achievers to allow staff and other parents to photograph individual students and groups of students to commemorate events and to promote various educational and social events related to the program. In addition to these, the teachers may take pictures of preschool events to be used for the enjoyment of all or for teaching purposes and publication to our Private Facebook Messenger Page.

Yes I give consent for the publication of my child’s photograph and comment for display within the building and classroom No I do not give consent for the publication of my child’s photograph and comment for display within the building and classroom

3. Private Facebook Messenger Group (ONLY PRESCHOOL PARENTS HAVE ACCESS TO THIS)

Yes, I give consent for the posting of my child’s photograph and comment on our Private Facebook Messenger Group (ONLY PRESCHOOL PARENTS HAVE ACCESS TO THIS) No, I do not give consent for the posting of my child’s photograph and comment on our Private Facebook Messenger Group

Date Signed

Print name of parent/guardian

Payment Options

Credit Card via Tithe.ly (a secure payment platform) Post-dated Cheques – provide 10 cheques dated for the 1st of each month, payable to NWLB E-Transfer- send funds each month to email: treasurer@NWLB.ca Pre-authorized debits (PAD)

Please note that cash payments are not accepted.
If you would like to set up pre-authorized debits, kindly attach a void cheque to this form.

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Preschool Application Form

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