Aleph Academy Enrollment Form

Basic Information

Child's Full Name*

First Name Last Name

Hebrew Name

Birth Date*

Month Day Year

Gender*

MaleFemale

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone

Requested Start Date*

Month Day Year

Program*

Full Year ProgramFull Summer 2026 ProgramSummer 2026 Session 1: July 6th -July 31thSummer 2026 Session 2: August 3rd- August 28th

School presently attending

Are you receiving fee assistance from Simcoe County?*

YesNo

Will you be applying for fee assistance through the county?*

YesNo

Name and address to which income tax receipt should be sent:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parents' Information

Mother's Name*

First Name Last Name

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone Number*

Occupation*

Place of Employment*

E-mail*

Mother Jewish By*

BirthChoiceOther

Mother's Hebrew Name*

Father's name*

First Name Last Name

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone Number*

Occupation*

Place of Employment*

E-mail*

Custody Information

Are there any special custody arrangements pertaining to access to/ visitation of your child? If yes please provide details

Child lives with*

Both ParentsFather onlyMother onlyOther

Please specify*

Who the child may be released to* Please include details of anyone other than parents

Emergency Contact Information

Emergency Contact Name 1*

Relationship to child*

Phone Number*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Contact Name 2*

Relationship to child*

Phone Number*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Medical Attention

Family Doctor*

First Name Last Name

Phone Number*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

I hereby grant permission for the Director and/or Supervisor to take whatever steps may be necessary to
obtain medical care if warranted. These steps may include, but are not limited to:
1. Contact a parent or guardian.
2. Contact emergency contact.
3. Contact a physician.
If we cannot contact you or your child’s physician, we will do any or all of the following:
1. Call an ambulance.
2. Have the child taken to the hospital in the company of a staff member.

Signature *

Medical Information

Does your child have a condition or behaviour that would require special attention, medication, or a special diet?

Does your child have any allergies (food, medication etc?)

Does your child have any childhood diseases

Child's previous history of communicable diseases (These may include Chickenpox, Diarrhea, Hepatitis A and B, Measles, Meningitis, Mumps, Pertussis, Rubella, Candidiasis, Conjunctivitis, Coxsackie A16, Fifth Disease, Pinworms, Scabies, and Streptococcal Infections)

Any Symptoms indicative of ill health/injuries/operations/etc

Skincare Consent
To ensure each child’s health and well-being, parents are required to provide the following skin care
products for use as necessary: sunscreen, insect repellant, diaper wipes, diaper cream. Each product
provided must be in its original container, clearly labelled, within the expiration date, appropriate for
the age of the child, and free of nut ingredients.
• I authorize daycare staff to administer the sunscreen product which I have provided.
• I authorize daycare staff to administer the insect repellant product which I have provided.
• I authorize daycare staff to administer the hand sanitizer product which I have provided, or that
which the daycare provides.
• I authorize daycare staff to administer the diaper cream or ointment which I have provided.
• In the event that products which I have provided are not available, I give permission to use a
suitable replacement.

I authorize daycare staff to administer any of the above*

Yes

Allergies

Description of Allergy

Signs of Reaction

Things child must avoid

Medication Instructions

Any other condition we should know about

Documents

Please upload your child's immunization record*

Please upload a recent photograph of your child*

I hereby consent to the collection, use, and disclosure of my child’s information by the daycare for the purposes of providing child care services. I understand that the daycare protects the privacy of all personal information in its possession in compliance with prevailing privacy legislation.*

Yes

I hereby grant permission for my child to use all of the play equipment and participate in all the activities of Aleph Academy. I hereby grant permission for my child to leave Aleph Academy under supervision of a staff member for neighbourhood walks or for any scheduled field trips.*

Yes

I hereby grant permission for my child be photographed/video recorded in all the activities of Aleph Academy.*

Yes

I hereby grant permission for photo/video images and/or sound recordings of my child to be used on bulletin boards, displays, presentations, and other promotional opportunities within the daycare.

Yes

I hereby grant permission for the daycare to use these photographs/videos/sound recordings of my child for the purpose of promoting Aleph Academy. This includes newspaper articles and ads, television productions and school related internet ads. I further grant permission for educational purposes such as bulletin boards, displays, presentations, and training , videos or webinars outside the daycare.

Yes

I hereby grant permission for any photo/video/sound images to be used for promotional and educational purposes on the Aleph Academy Website.

Yes

Signature*