McMASTER CHILDREN'S CENTRE, INC.

Entry Date___________________________	Requiring Subsidy: Yes______ No______
W.D. Date___________________________
Name of Child___________________________________________________________________________
Name child normally answers to_________________	Date of Birth__________________
Address__________________________________________________________________________________
Telephone_________________________
FATHER Name _____________________________________ Occupation_________________________________ Business Address___________________________ __________________________________________ Telephone _________________________________	MOTHER Name______________________________________ Occupation_________________________________ Business Address___________________________ __________________________________________ Telephone_________________________________
Other Information Third person to be called in an emergency. In the event that we are unable to reach either parent, it is imperative that we have this number. Name____________________________________ Telephone________________________________	Physician_________________________________ Address__________________________________ Telephone________________________________ Health Card Number________________________
Other Children in the Family Name Age Preschool Attended Present School ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Do you require Full Week or Part Week for your child? _______________________________________ If Part Week (not less than 3 days), please indicate preferred days.______________________________ What daily hours do you require?_________________________________________________________ Has your child attended any other day care centre? ____________Yes ____________No If so, for how long?_______________________________________________________________________ What is the earliest date you require care?_________________________________________________ What is the latest date you require care?__________________________________________________ A registration fee of $25.00 (non-refundable) is required upon acceptance. Four weeks notice in writing is required if you plan to withdraw your child. Failure to do so will necessitate fee payment for that period. Fee rates may be changed at the discretion of the Board of Directors. Please assist us in maintaining accurate records on your child by completing and returning all forms as quickly as possible. Please state why you need day care for your child and include any special circumstances which may contribute to this need. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
If you wish further information, please contact us at (905) 526-1222
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Signature of Parent(s)