Preschool Form - New Item

Preschool Location

North Delta

South Delta

Child's First Name *

Child's Middle Name

Child's Last Name *

Primary Contact Name *

Preferred Phone to Contact

Preferred Email for Contact

Child's Address

Child's City

Child's Postal Code

Child's Identified Gender

Male

Female

Specify your own value:

Has Indigenous Ancestry

If yes please check box

Date of Birth

Primary Language spoken at home

Translator Required

If yes please check box

Translation Required

Other Language Spoken at Home

Specify your own value:

BC Care Card Number

List child's allergies

Are any of the allergies anaphylactic?

Yes

No

Immunizations Up to Date

If yes please check box

Child's Diagnosis (if applicable)

Referral Reason

Not Parent/Guardian Section:

Please check this box if the person filling out this referral is not the Parent/Guardian

Not Parent/Guardian Section: Parent/Guardian is aware and consents to this referral

Yes

No

Not Parent/Guardian Section: Relationship

Not Parent/Guardian Section: Contact Info

Please put your name and phone number here

Parent/Guardian 1:

Parent/Guardian 1: First Name

Parent/Guardian 1: Last Name

Parent/Guardian 1: Relationship to Child

Parent/Guardian 1: Address same as child's

If same click box, if different then please fill in address fields.

Parent/Guardian 1: Address

Parent/Guardian 1: City

Parent/Guardian 1: Postal Code

Parent/Guardian 1: Phone

Parent/Guardian 1: Email

Parent/Guardian 2:

Parent/Guardian 2: First Name

Parent/Guardian 2: Last Name

Parent/Guardian 2: Relationship to Child

Parent/Guardian 2: Address same as child's

If same click box, if different then please fill in address fields.

Parent/Guardian 2: Address

Parent/Guardian 2: City

Parent/Guardian 2: Postal Code

Parent/Guardian 2: Phone

Parent/Guardian 2: Email

Parent/Guardian 3:

Parent/Guardian 3: First Name

Parent/Guardian 3: Last Name

Parent/Guardian 3: Relationship to Child

Parent/Guardian 3: Address same as child's

Parent/Guardian 3- Address same as child's

Parent/Guardian 3: Address

eg: 5678 Maple Street

Parent/Guardian 3: City

Parent/Guardian 3: Postal Code

Parent/Guardian 3: Phone

Parent/Guardian 3: Email

Content Type