Nursery Application Form
- Children 3 years of age
(turning 3 on or before December
31 of the current year)
- Children are required to be fully toilet trained
St. Mary's Campus
1541 St. Mary's Road
Winnipeg, MB R2M 3V8
Child Information:
Child's Legal Name
Known commonly as:
Date of Birth
MM
/
DD
/
YYYY
Home Phone
Gender
Male
Female
Child's Primary Residence
Postal Code
Year
2023-24
2024-25
2025-26
2024-25
Baptismal Birthday
MM
/
DD
/
YYYY
Religion
Languages known/spoken
Home School Division
Location
St. Mary's Nursery
Sept. - May
2 Days
(T & Th)
9:00-11:15
Yes
3 Days
(M/W/F)
9:00-11:15
Yes
5 Days
(M-F)
9:00-11:15
Yes
Mother Information:
Mother's Name
Mother's Cell Phone
Mother's Work Phone
Mother's Email
Mother's Residence: If different than child's primary address.
Mother's Name of work/school
Mother's Address of work/school
Occupation
Mother's Work/school Email
Father Information:
Father's Name
Father's Cell Phone
Fathers Work Phone
Father's Email
Father's Residence: If different than child's primary address
Father's Name of work/school
Father's Address work/school
Father's Work/school Email
Occupation
Custody Arrangements: Please complete if you do not live with child's other parent.
Living and Custody Arrangements
Child lives with:
Mother
Father
Guardian
If applicable, are there any separation agreements, court orders or other documents setting out custody arrangements for this child.
A copy must be provided to the school.
Yes
No
Are you aware that the childcare facility cannot ask the police to enforce custody arrangements if documents are not provided?
Yes
No
If applicable, are there any informal custody arrangements? Please describe:
Emergency Contact #1 (other than Mother/Father)
Name
Relationship to Child
Email
Emergency Contact phone number
Emergency Contact work phone number
Address
Address of work/school
Work/school Email
Emergency Contact #2 (other than Mother/Father)
Name
Relationship to Child
Email
Emergency Contact phone number
Emergency Contact work phone number
Address
Address of work/school
Work/school Email
Please list four other people who have permission to pick up your child from the childcare facility and/or school.
Medical Information:
Name of Doctor
Doctor's Phone Number
Address
Does your child have a life threatening allergy?
Yes
No
If yes, please indicate if your child has prescribed medicine:
Epipen
Inhaler
Personal Health Number
(9 digit)
Family Medical Number
(6 digits)
Medical Information: Allergies
Does your child have allergies to food, animals, medications etc., describe if yes:
Are there any cultural, religious, or personal requirements or restrictions that we should be aware of. If yes describe:
Describe any physical, developmental, social, emotional or medical conditions relevant to the care of your child. Please be specific and give suggestions about how we can best accommodate these needs.
Nursery/Daycare Specific Information
Toilet Learning
Select all that apply.
completely potty trained
asks to use the toilet
uses underwear all day
will not use the toilet
uses diapers at all times
Nap
Children who do not nap rest on a cot for 30 minutes.
I want my child to nap
Other:
If you selected other, please explain.
Is there any other information that may help us facilitate your child's transition into the childcare facility? (special interests, specific likes/dislikes, major changes with family, etc.)?
Acknowledgements & Permission
I understand that BSLS is a Lutheran School & Childcare and that all classes are taught from the prospective of the Lutheran faith. I have read and accept the policies outlined in the school handbook available online at bsls.ca.
Yes
No
I have read and agree to abide by the BSLS School & Childcare Parent Policy Manual and the Code of Conduct available online at bsls.ca. I will speak to the administration regarding any concerns I may have.
Yes
No
BSLS publishes a phone directory, which includes names, address, phone number, and email address. The purpose is for ride sharing, birthday parties, and inviting a friend over. I/We wish to share our information in the school directory.
Yes
No
We give permission for candid and professional photos to be taken of our child either individually or in a group setting. The photos may be used for promotional material including brochures, bulletin inserts, pamphlets, social media, emails, videos, website, blogs, etc. but are not limited to these. Pictures will be in good taste and complimentary to school and child.
Yes
No
I will notify the school/facility of any changes to the information provided on this form.
Yes
No
I give permission for outings within our neighbourhood not requiring transportation in private or public vehicle.
Yes
No
I give permission for indirect supervision as described in the childcare parent manual.
Yes
No
I give permission to discuss relevant information about my child's day with school and childcare staff.
Yes
No
If applicable describe any arrangements for school-aged children to attend activities away from the school/childcare facility at your request:
Emergency Medical Transportation and Treatment:
If, at anytime, medical treatment is necessary due to a serious injury or sudden illness, I authorize the childcare facility and school to take whatever emergency measures deemed necessary for the protection of my child while in the care of the childcare facility and school. I give permission for my child to receive medical attention deemed necessary by my child's doctor or other medical personnel. I understand that this may involve transportation to the hospital in a private vehicle or ambulance. I understand that the facility will make every attempt to contact me and that expense incurred for such treatment, including ambulance fees, is my responsibility.
Yes
Verification
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