New Family Registration

Family Registration Form

Parent or Caregiver Details

First Name	Last Name	Relationship to child (mother, father, grandmother, uncle etc.)	Gender	Language(s)	Ethnicity	Other / Multiple Ethnicities

Children Details

First Name	Last Name	Gender	Birth Date (Y/M/D)	Language(s)	Ethnicity	Other / Multiple Ethnicities

Address

Street

City

Postal Code

Telephone (Home)

Telephone (Cell)

Can we text you?

Yes

Emergency Contact

First Name	Last Name	Relationship	Telephone

MEDICAL CONDITIONS: Example – Allergic to peanuts

Name	Allergy or medical condition	Signs/symptoms	Any directions or medications

Any cultural restrictions or preferences (food)?

Any other information to share?

AUTHORIZATION/PERMISSION

I give permission for the Centre to use photos of my family members for promotional purposes on their website, Facebook page and other media.

Yes

I acknowledge you understand how we store, protect, and share information.

The information that you provide to any North End Parent Resource Centre Staff is deemed confidential whether it is provided to us verbally, on paper, or in electronic formats. It is protected by our policies of Confidentiality and Privacy. It may be stored electronically or in paper format. Our use of such information is to provide you with the best of programs and services possible as well as meet with our funding requirements. Any reporting of information provided to us is guided by policies and funder requirements. We only disclose aggregate data (grouped information without any names) and do not disclose individual names or particulars related to any individual.

BEHAVIOUR MANAGEMENT FOR CHILDREN

I acknowledge that I have been made aware of the North End Parent Resource Centre policy regarding Behaviour Management for Children.