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Kids on the Go Information Card

Please select one

GUEST today at Springs Springs in my HOME Church Information CHANGE

Child's Age

Child's Grade

N/A Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

First Name

Last Name

Child's Preferred name (or nickname)

Child's Birthdate

Please select one

Male Female

Mother's First & Last Name

Mother's Cell Phone

Father's First & Last Name

Father's Cell Phone

Child's Address (City, Province, Postal Code)

Primary Phone Number

If not the child's parent, how related

Grandparent Foster Parent Aunt/Uncle Other

Your name and phone number

Any allergies or medical conditions?

Yes No

If yes, what are they?

Are there any food restrictions?

Yes No

If yes, what are they?

Does your child require an Epi Pen?

Yes No

Does your child require a one-to-one support worker in daycare or school?

Yes No

Does your child take care of his/her elimination needs?

Yes No

Does your child use any prosthetic devices?

Hearing Aid Cane Wheelchair Walker Artificial Limbs

Any other prosthetic devices?

Any other special needs we should be aware of?

Do you have multiple children in the same household?

Yes No

Does your child communicate verbally?

Yes No

If not how do they communicate?

How does your child communicate his/her basic needs?

How does your child ask to use the washroom?

How does your child deal with people?

What is your child's diagnosis or medical conditions?

Is your child on any medication?

Yes No

If so how often does it need to be administered?

Media: Do you give permission to Springs Church to display pictures and/or video of your child for social media and/or promotional purposes?

Yes No

Security Card: I understand the security card issued to me will be required to pick up my child. I am aware if I misplace my security card I will be required to produce photo ID in order to pick my child up at the end of class. I understand this is for the safety of my child.

Yes No

Comments or questions?

Signature Printed

By checking this box you are signing this document digitally.

Please note that any names registered later than 12 noon on a Thursday may not be entered into the system by the following Sunday.

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Springs Church

Main Office: 725 Lagimodiere Blvd Winnipeg, MB R2J 0T8

(204) 233-7003

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