REGISTRATION APPLICATION

CHILD’S NAME_______________________________________ BIRTHDATE______________________

ADDRESS____________________________________________________________________________

HOME PHONE__________________________________EMAIL_________________________________

MOTHER’S NAME_______________________________CELL PHONE___________________________

OCCUPATION___________________________________________________________________

WORK PHONE_______________________________EMAIL_________________________________

FATHER’S NAME_______________________________CELL PHONE____________________________

OCCUPATION___________________________________________________________________

WORK PHONE______________________________EMAIL__________________________________

HOURS OF CARE REQUIRED: FROM _______________ TO _______________

WHAT IS YOUR CURRENT CHILD CARE ARRANGEMENT?____________________________________

NAME OF GROUP PROGRAMS CHILD HAS ATTENDED______________________________________

CHILD’S GENERAL HEALTH_____________________________________________________________

HAS CHILD BEEN DEVELOPMENTALLY TESTED?____________ If yes, describe any disabilities or

special needs: _________________________________________________________________________

CHILD’S PHYSICIAN_______________________________________PHONE______________________

IS YOUR CHILD FULLY IMMUNIZED?________________

REQUESTED START DATE_________________________________________________

WILL YOU BE APPLYING FOR A FEE SUBSIDY FROM THE CITY OF TORONTO? _________________

REFERRED TO GAN YELADIM BY: (please check one)
PRINT AD CHILDREN’S SERVICES PERSONAL REFERRAL INTERNET

THIS IS AN APPLICATION FORM ONLY. ACCEPTANCE TO GAN YELADIM IS BASED UPON THE AGE OF THE CHILD, CENTRE VACANCIES AND DATE APPLICATION IS RECEIVED