Rural Response for Healthy Children
Kinderoo Registration Form 2017
Program Dates
Tuesdays, Wednesdays, Thursdays from July 4th to August 10th 2017
Program Locations & Times
Clinton (morning), Exeter (afternoon),
Goderich (morning OR afternoon), Wingham (morning OR afternoon)
Exact locations to be confirmed in early June.
Mornings = 8:30 am – 11:30 am Afternoons = 1:00 pm – 4:00 pm
The fee for Kinderoo 2017 is $200 per child. Payment is due upon registration to confirm the child’s spot at the
preferred location and time. IF the preferred location and time is full, you will be offered a different location
and time, pending space. Registration is on a first come, first serve basis.
Completed registration forms and payment may be mailed to
Rural Response for Healthy Children
PO Box 687
Clinton Ontario N0M 1G0
Cheques are payable to ‘Rural Response for Healthy Children’
There are other options for registration. Please refer to www.rrhc.on.ca/kinderoo for more information.
If you have questions, please contact
Jill Robertson, Kinderoo Coordinator at 519-482-8777 or email [email protected]
Please complete the following information to register your child. If you are registering more than one child,
please complete a form for each child.
Preferred Location:
Child’s Full Name:
Child’s other name if they are not called by their first name:
Child’s Date of Birth:
Mother’s Name (Guardian):
Father’s Name (Guardian):
Address:
Telephone:
Email:
What school will your child be attending in September 2017:
P age 1|7
Rural Response for Healthy Children
Kinderoo Registration Form 2017
Emergency Contact:
Name
Relationship
Telephone
Pick Up and Drop Off
All people with permission to pick up your child must provide picture identification and a signature.
Please list all people who will pick up your child and will provide identification.
Allergy/Medical Condition(s)
Symptoms:
Treatment:
Family Doctor:
Family Doctor Phone #:
Health Card Number:
P age 2|7
Rural Response for Healthy Children
Kinderoo Registration Form 2017
Rural Response for Healthy Children provides a safe, nurturing and stimulating learning environment.
Parents/Guardians who register a child for Kinderoo are required to read, sign and date each of the following
policy statements, thereby acknowledging that they understand the policy and agree to abide by it.
Feel free to ask if you have any questions or would like to discuss the policies.
Pick Up & Release Procedures
We are not able to release any child into the custody of any person who has not been preauthorized on the registration form completed by the child’s Parent/Guardian.
The authority to release a child to someone other than indicated on the completed registration
form is accepted only if it is provided to us in writing, in advance, and is signed by the
Parent/Guardian. Please note that the person picking up the child may also be asked to produce a
Photo Identification and sign when he/she comes to pick up the child.
I have read and understood this policy?
Yes
No
Initial: __________
Illness & Medications
Please note that it is important to control the spread of illness and if your child is ill we
recommend they do not attend the program during that time period. Also recognize that staff
will not administer medication to any child, except under life threatening circumstances, such as
using an Epipen for bee stings or peanut allergies.
I have read and understood this policy.
Yes
No
Initial: __________
Food Restrictions
KINDEROO – School Readiness Program is a nut free environment, as this is an existing policy
in schools. We ask that you keep morning breakfast nut free if possible. If this is not possible,
please be sure to wash your child’s hands and face thoroughly prior to coming to the
KINDEROO – School Readiness Program.
I have read and understood this policy.
Yes
No
Initial: __________
P age 3|7
Rural Response for Healthy Children
Kinderoo Registration Form 2017
Permission to Provide Emergency Medical Care
I hereby grant permission for staff at the KINDEROO – School Readiness Program to take
whatever steps may be necessary to obtain emergency medical care if warranted. These steps
include but are not limited to the following:
1) Attempt to contact the Parent/Guardian using telephone numbers you have provided and are
on file with the facilitators on site.
2) Attempt to contact the designated emergency contact using telephone numbers you have
provided on the registration form.
3) Seek emergency medical treatment from a physician or a hospital.
If first aid or CPR is necessary trained facilitators are in a position to administer until emergency
personnel arrive. Rural Response for Healthy Children will not be responsible for anything that
may happen as a result of false information given at the time of registration. RRHC staff will
endeavour to put the well-being of the child first in an emergency situation.
I have read and understand this policy.
Yes
No
Initial: __________
Consent to Photograph or Videotape
I hereby consent to my child being photographed or videotaped by employees of Rural Response
for Healthy Children for non-commercial display purposes. Such as, pictures, family trees or
bulletin boards for Kinderoo School Readiness activities.
Yes
No
Initial: __________
Consent to Singing the National Anthem
I hereby grant permission for my child to sing the national anthem every morning as a part of the
KINDEROO – School Readiness Program daily routine.
Yes
No
Initial: __________
P age 4|7
Rural Response for Healthy Children
Kinderoo Registration Form 2017
DEVELOPMENTAL INFORMATION
Socialization:
 Does your child have experience in a day care or other childcare settings?
 How much experience does your child have with children outside the family home? (play groups/friends)
 Does your child have siblings? Are they older/younger?
 What type of play does your child like best?
Playing Alone? _____ Watching Others Play? ____
Playing with Others? ____
 Does your child have anxiety around other children?
 Does your child show helpful problem solving skills with other children?
 Does your child have any fears?
P age 5|7
Rural Response for Healthy Children
Kinderoo Registration Form 2017
Routine:
 How is your child with basic structure and routine? Does you child understand and follow house rules like
sitting at the table, not jumping on the couch?
 Does your child exhibit attention difficulties (ie: ability to sit through a story)?
 Eating Habits:
 Sleeping Habits:
 Is your child toilet trained?
Communication
Please check one:
Little communication (concerned)__
Average communication__ Good communication__
 Comments
Emotional
 How does your child deal with conflict?
P age 6|7
Rural Response for Healthy Children
Kinderoo Registration Form 2017
Temper Outburst__
Crying __
Avoids __
Submissive (never challenging, backs down) ___
 Comments
Change/Transition – How does your child manage change:
 Does your child have anxiety around change in routine?
Yes ____
No ____
If yes, explain
Does your child have difficulty with transitioning between activities? (general daily tasks) Yes ___ No ___
If yes, explain
Number/Letters- How well does your child know their letters or numbers?
Does your child know the alphabet?

Yes____
No____
If yes, can they recite the whole alphabet or part of it?
Printing Your Name: How well does your child print their name?
Is your child able to print their name?

Yes___
No___
If yes please explain how well.
P age 7|7