WeeTrack

Application for Childcare Enrollment

PARENT/GUARDIAN INFORMATION

Parent/Guardian 1 First Name:*

Parent/Guardian 1 Last Name:*

Address:*

City:*

Postal Code:*

Home Phone:

Province:

Work Phone:

Cell Phone:*

Email:*

Gender:

Male

Female

Other

Relationship to Child:*

Employer Name/City:*

Parent/Guardian 2 First Name:

Parent/Guardian 2 Last Name:

Same address as Parent 1

Address:

City:

Postal Code:

Home Phone:

Province:

Work Phone:

Cell Phone:

Email:

Employer Name/City:

Gender:

Male

Female

Other

Relationship to Child:*

Custody Arrangements (if applicable):

Are you subsidized or applying for childcare subsidy?:*

Yes

Languages spoken at home:

CHILD INFORMATION

Child’s First Name:*

Child’s Last name:*

Gender:*

Male

Female

Other

Date of Birth:*

Child’s Home Address:

Same as Parent 1

Same as Parent 2

Address:

City:

Postal Code:

Province:

Names/ages of siblings (note: a separate application must be completed for each child):

Name and Location of Child’s school (if applicable):

General Health: Any known allergies, health or medical conditions?*

Yes

If yes, please describe:*

Does your child require any special food or liquids or any special diet?*

Yes

If yes, please describe:*

Please indicate preferred area for daycare, and outline any additional comments or requirements regarding the care of your child:

Status:

SCHEDULE AND LOCATION

Date childcare required:*

Days of the week child needs to be in care:*

Please indicate care required:*

Hours each day child needs to be in care:*

Days

Evenings

Weekends

Overnights

Start Time:*

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End Time:*

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Varied Hours:*

Days and Hours of the week Parent 1 works:

Closest intersection to home:*

Closest intersection to work:*

Days and Hours of the week Parent 2 works:

Closest intersection to home (Parent 2):

Closest intersection to work (Parent 2):

PREFERENCES

What is most important to you in selecting a childcare Provider?:*

Are you open to place your child with a Provider with pets?*

Yes

How did you hear about Wee Watch?

Friend/Family Google Facebook/Instagram Print ad Radio Other

Describe

PHYSICIAN AND EMERGENCY CONTACTS

Physician’s Name:*

Phone Number:*

Persons to contact in an emergency if parents cannot be reached, and to whom the child may be released:

Full Name:*

Phone #:*

Relationship:

Full Name:*

Phone #:*

Relationship:

Full Name:

Phone #:

Relationship:

SIGNATURES

Signature of Parent/Guardian:*

Date:*

The agency will contact you to discuss your needs, answer your questions and advise you of the registration fee