Submissions are received every Monday, please allow one week to receive a response confirming your child's spot on the waiting list. If you do not hear from us within one week, please give us a call at 450-632-7603 ext. 1. Back I acknowledge Child’s Name (* indicates a required field)* Date of Birth* Please select a month January February March April May June July August September October November December Month Please select a day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day Please select a year 2024 2023 2022 2021 2020 Year * Boy:Girl: Parents/Guardians Mother’s Name * Phone #* Cell/Other #* Full Address* Full Address 2* E-Mail Address* example@example.com Father’s Name* Phone #* Cell/Other #* Full Address* Full Address 2* E-Mail Address* example@example.com Alternate Contact Person (in the event you cannot be reached): Name* Phone #* PLEASE NOTE: All applications are considered for full time daycare. As part-time spots are limited, a determination will be made upon acceptance. Step by Step Child & Family Center (SBS) hours are 7:30 a.m.-5:00 p.m. daily for children aged 18 months to 4 years-old. SBS is no longer able to accept waiting list applications from expecting parents, please submit the application after your child’s birth date. Any outstanding daycare balances that parents have previously incurred from SBS, Seven Generations or Karihwanoron, must be paid in full before we can consider your application. 1) Please check all that apply: Are you currently employed?* YesNoFull-TimePart-Time Where are you currently employed? Please check all that apply: Attending School?Stay-at-home Mom? Marital Status?* MarriedSingleBlended FamilyDivorcedCommon-LawSeparatedWidowed Is the child living with both parents?* YesNo 2) Describe your child and his/her strengths.* 3) Do you have any concerns about your child’s learning or development? HearingVisionSpeech/LanguageBehaviorEatingSleepingPhysical Development Explain 4)Are there any difficult behaviors requiring attention? (i.e. kicking, biting, scratching, pushing others etc.) 5) Have there been any major changes in the life of your family that may be affecting your child? i.e. a recent move, a death, a divorce/separation 6) Why do you want your child in Daycare?* 7) If you are planning on sending your child to a Kanien'kéha immersion school at 4 years of age, please select "yes" so we may place your child on the Kanien'kéha readiness waiting list. Please note that there are limited spots, while selecting "yes" does not automatically guarantee a spot in this classroom, we will do our best to accommodate your selection.* YesNo CONFIDENTIAL SCHOOL MEDICAL RECORD DOES YOUR CHILD HAVE...? If you answer “YES” to any of the following questions, please include explanation and treatment details. If additional space is needed please use the back of this sheet. 1. RESPIRATORY PROBLEMS (i.e. ASTHMA or other lung/breathing problem)2. ALLERGIES - Please specify to what: Is an EPIPEN required?3. NEUROLOGICAL PROBLEMS (i.e. Seizures, migraines)4. HEART PROBLEMS5. VISUAL PROBLEMS (most recent test results may be required upon registration)6. HEARING PROBLEMS (most recent test results may be required upon registration)7. GASTROINTESTINAL PROBLEMS i.e. (stomach, bowels, liver)8. ENDOCRINE PROBLEM (i.e. diabetes, growth disorder)9. URINARY PROBLEMS10. BONE, MUSCLE OR JOINT PROBLEMS11. SKIN PROBLEMS12.ANY OTHER CONDITION THAT EFFECTS HIS/HER EMOTIONAL OR PHYSICAL WELL BEING Please explain below13. DOES YOUR CHILD REQUIRE ANY MEDICATION?14. HAS YOUR CHILD EVER BEEN HOSPITALIZED? Please explain below15. WAS YOUR CHILD PREMATURE? If so, by how many weeks? Explanations for #'s 12-15 above I am responsible for notifying the center of any changes made to the information in this form regarding my child. Signature* Date* /Month /DayYearDate Please click the button below to send your information. Submit Should be Empty:
