Kids Place Application
Full-Time or Part-Time Care
Are you applying for after school care on a full-time or a part-time basis?
Full-Time
Part-Time
Approximately how many days per month do you anticipating needing care for this child?
School-Age Social Resume
Parent/Legal Guardian Name
Phone Number
Email Address
Home Address
Mailing Address
Mailing City
Mailing Province
Mailing Postal Code
Child's Information
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
School Grade
-- None --
Nursery/Pre-school
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
School Name
School Address
How will your child get to and from school?
School Phone Number
Is a transportation company involved? (taxi, bus service)
Yes
No
Name of transportation company.
Transportation company phone number
Family
Sibling Name
Sibling Name
Sibling Name
Sibling Name
Sibling Name
Sibling Birthdate
Sibling Birthdate
Sibling Birthdate
Sibling Birthdate
Sibling Birthdate
Do any of these siblings live at a different home than this child?
Yes
No
Please list the names of the siblings living at a different home
Are there others living in the same homes as the child?
Yes
No
Name
Relationship to child
What languages are spoken in your home?
Does your child have any pets?
Yes
No
Please list the child's pets
Food
Describe your child's appetite
What foods do you NOT permit your child to eat?
What time does your child usually eat breakfast?
What time does your child usually eat lunch?
What time does your child usually eat supper?
What time does your child usually eat snack?
Please provide any further information relating to your child with regard to food or eating.
Self-Care
Does your child need help with dressing?
Yes
No
Please identify the areas of difficulty
Does your child need help with toileting?
Yes
No
Please identify areas where assistance is required
Social/Emotional Development
How often does your child show affection?
How often does your child worry?
How often does your child show fear?
How often does your child show anger?
How often does your child show frustration?
How often does your child show excitement?
Is your child shy?
Yes
No
Sometimes
With whom?
When?
Does your child enjoy playing by him/her self?
Often
Sometimes
Never
Does your child enjoy playing with younger children?
Often
Sometimes
Never
Does your child enjoy playing with own-age children?
Often
Sometimes
Never
Does your child enjoy playing with older children?
Often
Sometimes
Never
Does your child enjoy being with adults?
Often
Sometimes
Never
Does your child make new friends easily? Please explain.
Does your child have any imaginary playmates?
Yes
No
Please Explain
What activities does your child like?
What activities does your child dislike?
Is your child enrolled in any extra curricular activities?
Yes
No
Please List
How do you handle discipline in your home?
What characteristics in your child's development would you like encouraged?
What characteristics in your child's development would you like discouraged?
Provide any further information relating to your child that would be helpful in understanding and caring for your child
Referral Information
How did you hear about Kids Place Afterschool Care?
Facebook
News
Referred by a friend
Friend's Name
Please read and check the following boxes before submitting your child's resume
By checking this box, you are acknowledging that you understand that personal health information may be disclosed by the facility to the Ministry of Education in the course of reviewing the facility's record keeping obligations.
*
I agree
By checking this box I acknowledge that I am submitting an application for a spot for my child in the Kids Place After School Care program, and that I will be contacted when a spot is available for my child.
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I agree
Submit