ABORIGINAL HEAD START ON RESERVE PROGRAM REGISTRATION FORM ABORIGINAL HEAD START ON RESERVE PROGRAM REGISTRATION FORM ABORIGINAL HEAD START ON RESERVE PROGRAM REGISTRATION FORM 2020-2021 Child Identification Name of Child: * Gender: * Male Female Date of Birth: * Treaty Number: * Alberta Health Number: * Mailing Address: * City: * Province: * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code: * Civic Address: * City: * Province: * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code: * Parent(s) / Guardian(s): First Name * Last Name * Relationship to Child * Mother Father Step-Mother Step-Father Foster Mother Foster Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Other Relative Other (Please specify) Relationship to Child Home Phone * Cell Phone Work/School Please list names and ages of your child's brothers and sisters First Name * Last Name * Age * List names of people who have authorization to pick up / drop off your child(ren) from Head Start (other than parents or emergency contacts) First Name * Last Name * Health & Nutrition Is your child's immunizations up to date? Yes NoNo NOTE: Each child utilizing the Bigstone Cree Nation Head Start Program must be up to date in their immunization. This precaution is for the health and safety of your child. Drinks from: * Cup Baby Cup Food: * Table Food OtherOther Food she/she likes: Food she/she dislikes: Any allergies (food, drinks, and materials)? * Yes (Please specify)Yes (Please specify) No Does your child have a dietary restriction? Yes (Please specify)Yes (Please specify) No If your child has dietary restriction, you are requested to provide alternatives to our menu. Please bring them in the morning. Is there any health problems that may be serious or require special attention? Yes No Please specify * Physician's Name * Contact Number * Nap Time / Quiet Time: Does your child nap during the day? * Yes No When: * 121234567891011 : 00153045 AMPM How long does she/he rest for? * Does your child have a security blanket? * Yes No Does your child had previous Head Start or Daycare experience? * Yes (Please specify)Yes (Please specify) No Does your child have any difficulties with speech, hearing, etc.? * Yes (Please specify)Yes (Please specify) No Does your child speak and/or understand Cree? * Yes No Does your child have any special interests? * Yes (Please specify)Yes (Please specify) No Is your child afraid of anything? * Yes (Please specify)Yes (Please specify) No Does your child throw tantrums? * Yes (Please specify)Yes (Please specify) No What form of discipline do you use at home? * Parents are encouraged to volunteer time in the Head Start Program, as Parental Involvement is one of the components of the Aboriginal Head Start On Reserve Program. Would you be willing to volunteer some time? Yes No Is there a particular time/day that is best suited to you? Monday Tuesday Wednesday Thursday CHILD'S SKILLS Colors * Yes Trying Not yet apparent Use writing tools for doodling, etc. * Yes Trying Not yet apparent Communicates in complete sentences * Yes Trying Not yet apparent Pasting * Yes Trying Not yet apparent Reads * Yes Trying Not yet apparent Brushes teeth * Yes Trying Not yet apparent Feeds self * Yes Trying Not yet apparent Wash self * Yes Trying Not yet apparent Dresses self * Yes Trying Not yet apparent Ties laces on shoes * Yes Trying Not yet apparent Potty trained * Yes Trying Not yet apparent Plays well with others * Yes Trying Not yet apparent Field Trips Is your child permitted to go on supervised field trips while in the BCN Aboriginal Head Start On Reserve Program? * Yes No PARENTAL CONSENT * Dear Parent/Guardian: As a part of our Head Start Program, the staff takes the children for nature walks; visit the playground at Oski Pasikoniwew Kamik (Band School); swimming at the Wabasca Water World and Fitness Center, as well as visiting the Lake View Sports Center (Multi-Plex), or any other (i.e. Taron’s Ranch, Kapaskwatinak, or community businesses, etc.) We are required to obtain parental consent form for each time the child participates in one of the above activities, once parental consent will be used for the period of time between February – July 2021. Please sign the bottom section of this form if you would like your child to participate. If you have more than once child in the Head Start Program, please sign one for each child and return the forms to Head Start. The consent forms will be kept in your child’s file. Signature of Parent/Guardian * Clear Date of Signature FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY COPYRIGHT RELEASE FORM Student's Full Name: * I hereby grant permission to Aboriginal Head Start On Reserve (AHSOR), on behalf of my child(ren) for the following: (Please check appropriate boxes) * Videotape/Record my child Display my child’s work Reproduce any of my child’s work Photograph of other representation of my child None of the above * For the purpose of educational purpose: wall displays, special projects (Mother’s Day, Father’s Day, Christmas, etc.) I understand the production(s) work(s) may be shown at: educational displays open house, in-service sessions, online Facebook Page, and other school related activities at school or school board sites, or school board sponsored displays in the community; or used in a school publication. For example: year books, wall displays, school newspaper, community newspaper, Bigstone Cree Nation newspaper, The Fever newspaper or any other videotaping, etc. Signature of Parent/Guardian * Clear Date of Signature reCAPTCHA Submit If you are human, leave this field blank.
