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Date of Application
Proposed Start Date
Surname
Date of Birth
Street Address
Given Names
Gender
City
Postal Code
Arrival Time
Departure Time
Is there a current custody agreement? (Y/N)
Are there any Custody agreements pertaining to access to/restrictions of your child? (Y/N)
*If yes, a copy of the Custody Agreement/Court Order must be provided to the Centre Director prior to starting
Previous Care (home with parents, licensed day care, home childcare, relatives)
List of languages spoken at home
Comment on your child’s general temperament. (friendly, outgoing, shy, active, very active, physical)
Comment on your child’s Social Skills: (i.e Prefers to play alone/or in groups, follows routines/verbal directions, cooperative/strong-willed)
List some of your child's favourite activities:
Does your child require special care due to Developmental Needs? (Y*/N *If Y please explain)
List any dietary restrictions due to allergies (Please be specific e.g. EGGS cooked/uncooked/ingredient)
List any dietary restrictions due to religion/preferences
Dresses
YesNo
Feeds
Toilets
AM
PM
Time Duration
Does your child have any allergies?
Is your child considered anaphylactic?
Epi Pen information complete?
Is your child taking any medication?
If yes, what is the purpose of the Medication?
Childcare Subsidy
Subsidies are available to offset the cost of childcare for eligible lower-income families.
Eligible lower- to middle-income families can apply for childcare subsidies if they have a child enrolled in a:
licensed facility-based programs
family day home programs overseen by a licensed family day home agency
Learn about the maximum subsidy rates . These vary by program type and the age of child attending childcare. For more information, visit https://applychildcaresubsidy.alberta.ca/