Infant

General Information

Child's Name*

First Last

Birth Date (dd/mm/yyyy)*

Present Age*

Please enter a number from 0 to 30.

Gender

Male
Female

Parent's Names:

Father's Name*

Prefix First Last

Mother's Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone Numbers:

Home Tel:*

Father's Cell Phone*

Father's Email*

Father's Occupation*

Father's Employer*

Father's Work Address*

Father's Work Phone Number*

Mother's Cell Phone*

Mother's Email*

Mother's Occupation*

Mother's Employer*

Mother's Work Address*

Mother's Work Phone Number*

Parent's Marital Status*

Married
Divorced
Separated
Widowed

Emergency Contact

Name*

First Last

Phone*

Relationship to Student*

Student Profile

Languages spoken at home*

Please upload a current photo of your child.

Medical Information

Doctor's Name*

First Last

Doctor's Phone Number*

Doctor's Address*

Diagnosis (if applicable)*

Please list all diagnosis

Do any of the following apply to your child:*

Seizures
Heart Condition
Respiratory Issues
Feeding Issues
Hearing Issues
Low Muscle Tone
Other Medical Condition

Does your child have any allergies?*

Yes
No

If yes, please list:

Please list all prescribed medications child is currently taking*

My child's Immunization Form will be*

uploaded here
sent in to the school office

Please upload immunization records here.

I allow KCC to share immunization information with York Region Public Health Department.*

Yes
No

Does your child have any specific Dislikes/Fears that we should be aware of?*

Good tips to know

My child has had a formal assessment from by a qualified health care professional.

Physiotherapist
Speech Therapist
Occupational Therapist
Other

Assesments will be

uploaded here
sent in to the school office

Please upload assessments here.

Photo Release*

Photos help KCC share the success of the program with potential families and our generous supporters. At no time will children's names and/or personal information be shared along with the photos without written consent. We greatly appreciate families who consent to a photo release.

You may photograph my child for use in brochures, media and website
My child may be included in group photos only
Please contact me before using my child's photo in print material
My child is not photo released

Terms and Conditions*

I confirm the information in this application is complete and accurate.
I understand that this will be followed by an intake interview

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Name

This field is for validation purposes and should be left unchanged.

2019-2020 Infant Application

General Information

Emergency Contact

Student Profile

Medical Information