Child Care Registration

Step 1 of 8

Child Information
Child Name*
First Middle Last
Date of Birth*
Gender*
- Female
- Male
Address*
Street Address City ON Postal Code
Age Group*
- Infant ( under 18 months )
- Toddler ( 18 - 36 months )
- Preschool ( 2.5 - 5 years )
- Kindergarten ( 4 - 5 years )
- School Age ( 6 - 12 years )
Length of care required*
Note: Part-Time care requires a set schedule and availability depends on location (See Wait List Policy)
- Full Time
- Part Time
School age care required*
- Before AND After school
- Before school
- After school
Toddler Centres
Below is a list of Child Care Centres available based on your selections above.
Pre-school Centres
Below is a list of Child Care Centres available based on your selections above.
Kindergarten / Before and After School Centres
Below is a list of Child Care Centres available based on your selections above.
School for St Anthony
Please select which school your child will be attending while enrolled with YMCA Child Care.
School for Burnham
Please select which school your child will be attending while enrolled with YMCA Child Care.
School for Grafton
Please select which school your child will be attending while enrolled with YMCA Child Care.
Staff Referral*
Did the YMCA Child Care Supervisor for the above Centre direct you to this online form?
Preferred Start Date*
Please select a preferred starting date for Child Care.
YYYY dash MM dash DD
Drop Off times*
When will you be dropping off your child? (e.g. 6am, 8:00am)
Monday Tuesday Wednesday Thursday Friday
Pick Up times*
When will you be picking up your child? (e.g. 5pm, 6:30pm)
Monday Tuesday Wednesday Thursday Friday
Diapers / Toilet Training
Does your child use diapers?*
- Yes
- No, but requires some assistance
- No, but requires full support
- No, my child uses the washroom independently
Toilet / Bathroom notes*
Please provide any addition notes about bathroom use if necessary
Age of Child

Parent Information 1
Parent Name 1*
First Middle Last
Date of birth*
Relationship to child*
Phone*
Alternate Phone
Email*
Parent Address Info
- Address is the same as child
Parent 1 Address*
Street Address City Province Postal Code
Parent Information 2
Parent Name 2
First Middle Last
Date of birth
Relationship to child
Phone
Alternate Phone
Email
Parent 2 Address Info
- Address is the same as child
Address
Street Address City Province Postal Code

Emergency Contact 1
In the event of an emergency and the parent(s) cannot be reached please list in order of preference, individuals that should be contacted.
Emergency Name*
First Last
Phone*
Relationship to Child*
Address*
Street Address City Province Postal Code
Authorized to pick up Child?*
Emergency Contact 2
Emergency Name 2*
First Last
Phone*
Relationship to Child*
Address*
Street Address City Province Postal Code
Authorized to pick up child?*

Consent
Photo Release
Our Child Care Centres may use photographs, images and/or recordings containing the Registrant’s picture, image, voice and/or other likeness for promotional, advertising, public relations and/or informational purposes.
I hereby consent to the use of these materials without further notice or compensation, in any publicity or advertisement carried out by YMCA Northumberland
Swim and Gymnasium Consent
YMCA Child Care programs are enhanced by the opportunity to participate in swimming and gymnasium time offered by the Cobourg YMCA. A full schedule of swim dates for your centre will be provided by the site supervisor. Supervision will be provided by Child Care staff along with YMCA Lifeguards.
I give permission for my child to participate in both swimming and gymnasium programs offered at YMCA facilities
Field Trip Consent
Short, local field trips will be provided by the child care centre at various times throughout the year. Trips could be as simple as a walk to the playground or around the block. All trips will be on foot and supervision will be provided by the YMCA Staff. These trips are important for the enhancement of your child's experience. Specific consent forms will be sent home for special field trips that require busing or other transportation.
I give permission for my child to participate in short local field trips
Information Sharing Consent
YMCA Northumberland is a partner with the School Board and as such will require permission for the reciprocal exchange of information including, but not limited to, matters regarding your child’s educational supports, attendance, health and safety, transportation, wellness and/or behaviour. Please note that consent is required in order to register in any YMCA before and after school program.
I give permission for the reciprocal exchange of information with the School Board
Online Form Registration*
I understand that by submitting this form that it does not register my child for care. This form is a tool that allows Child Care staff to make the registration process easier for the parent. After submission a YMCA staff member will contact me to arrange a site visit where final registration will happen.
I agree to the above statement
Captcha

Memberships

Fitness

Aquatics

Child Care Registration

Step 1 of 8

Child Information

Diapers / Toilet Training

Parent Information 1

Parent Information 2

Emergency Contact 1

Emergency Contact 2

Custody

Pick Up and Additional Emergency Information

Health and Medical

Allergy Info

Infant Dietary Information

Feeding

Dietary Information

Infant Sleep Arrangements

Sleep Information

Physical Requirements

Skin Products

Additional Information

Consent

Useful Links

About us

YOUTH

First Name	Last Name

First Name	Last Name

Full Legal Name	Relationship to Child	Primary Phone

Nap time	Length of nap