Waiting List Form

Tsi ionterihwaienhstahkwa ne Kahwatsiranó:ron
Step By Step Child and Family Center
P.O. Box 771 Kahnawake Mohawk Territory, QC J0L 1B0
Tel: (450) 632-7603
Fax: (450) 632-3357
E-mail: info@stepxstep.ca
Website: www.stepxstep.ca
Child’s Name (* indicates a required field)*
Date of Birth*

MonthDayYear
*

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?*
7Please indicate if you would like to place your child on our Kanienke’ha class waiting list?*

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*

MonthDayYear
Date
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Parents/Guardians

PLEASE NOTE:

CONFIDENTIAL SCHOOL MEDICAL RECORD