Highroad Children's Centre

Highroad Children's Centre

Package
Office Use Section
Does the following application require applicant to make any changes?

YesNo
What is the status of the application?

EnrolledApplication WithdrawnPendingNot acceptedOn Hold/Waitlist
Date of Application Withdrawn

MonthDayYear
Date
Date of Enrolled

MonthDayYear
Date
Welcome to the Highroad Children's Centre online registration
After completion of this form, the office staff will review your application. Once it has been reviewed, you will be sent a tuition contract via your email. The tuition contract is where you will select which classes you will be applying to. In the event that classes are filled up, your application will be put on a waiting list. Should you have any questions, feel free to reach out to Leslie Dueck at ldueck@highroadchildrenscentre.com.
Will you be applying to attend Highroad Academy after your kid finishes preschool?*

YesNoUndecided
Select one of the following*

HCC RenewalsHRA AlumniCommunity Applicant
1. Student Information
When are you registering for?*

2024-20252025-2026
Year
Gender of Applicant?*

MaleFemale
Date of admission requested*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Address*

Street Address

CityProvince

Postal / Zip CodeCountry
Date of birth*

MonthDayYear
Date
Place of birth*
Student's Status in Canada*

Canadian CitizenLanded ImmigrantTemporary VisaOther
Explain*
Is the Parent/Legal Guardian a resident of BC?*

YesNo
Personal Health Number*
Are there other children in your family?*

YesNo
What are their names and Birthdates?*
Are there pets in your family?*

YesNo
What kind of pets and what is their names?*
Is English your child's first language?*

YesNo
If not, what language is his/her first language?*
Language spoken at home*
2. Parent/Guardian:
Parent/Guardian 1*

First NameMiddle NameLast Name
Address*

Street Address

CityProvince

Postal / Zip CodeCountry
Home or Cell Number*
Please enter a valid phone number.
Work Number (if applicable)
Please enter a valid phone number.
Email*
example@example.com
Are you an HRA Alumni?*

YesNo
If yes, what year did you graduate?*
Employer*
Occupation*
Relationship to Child:*
Martial Status:*

MarriedWidowedDivorcedSeparatedSingle
3. Parent/Guardian:
Parent/Guardian 2

First NameMiddle NameLast Name
Is the address for Parent/Guardian 1 the same for Parent/Guardian 2?

YesNo
Address

Street Address

CityProvince

Postal / Zip CodeCountry
Home or Cell Number
Please enter a valid phone number.
Work Number (if applicable)
Please enter a valid phone number.
Email
example@example.com
Are you an HRA Alumni?

YesNo
If yes, what year did you graduate?
Employer
Occupation
Relationship to Child:
Martial Status:

MarriedWidowedDivorcedSeparatedSingle
4. Additional Information
Student resides with:*

Father & MotherFatherMotherLegal Guardian
Is there a custody order in place?*

YesNo
If yes, please provide a copy with this form*

Cancelof
Does the applicant have First Nations Status?*

YesNo
If yes, do you live on a reserve?*

YesNo
Band name*
Do you attend a church?*

YesNo
Which Church do you attend?*
Do you have any church background?*
Emergency Contacts
Primary emergency contact*
Phone*
Relationship to student*
Secondary emergency contact*
Phone*
Relationship to student*
Family doctor*
Phone*
In case of accident or illness I authorize the Centre staff to contact a physician and/or ambulance if a parent or guardian cannot be reached immediately.*

Yes
I authorize the following people to pick up my child/ren from the Preschool facility:
Contact 1*

First NameLast Name
Relationship*
Phone Number*
Contact 2

First NameLast Name
Relationship
Phone Number
Contact 3

First NameLast Name
Relationship
Phone Number
3. Personal Information
What type of programs/sports has your child been apart of? *
What interests/activities do your child enjoy? *
A. Developmental Skills
Has your child ever been assessed or diagnosed with any type of learning disability?*

YesNo
If so, which category/designation*
Has your child ever been involved with outside services such as: FVCDC*

YesNo
Do you feel concerned with any areas of your child's development or suspect your child may have ADD/ADHD or Anxiety*

YesNo
If yes, please explain
Have they ever been seen by a paedictician for specific developmental concerns*

YesNo
Please explain*
Would you like to meet with us to go over any concerns and see what support we could provide you?*

YesNo
B. Social Skills
Have there been any significant changes in the child’s life during the past year (example: move/death/separation)?*

YesNo
Please provide details*
Does your child have any specific fears that affect his or her behavior?*

YesNo
If so, what are they?*
Children must be toilet trained to attend preschool. Is your child toilet trained?*

YesNo
If not, do you feel that he/she will be before preschool starts?*

YesNo
Has your child attended daycare, preschool or Sunday school/are theycurrently attending one of these?*

YesNo
Please indicate where*
C. Medical
Does your child have any allergies, food intolerances or medical conditions?*

YesNo
Please explain:
Does your child take any prescription drugs on a regular basis?*

YesNo
Please provide detail*
D. Financial
E. Miscellaneous
Is there any other information pertinent to your child's registration?*
*To receive the affordable child care benefit discount for September. Please say yes and fill out this form immediately to avoid any delay in processing the discount.
Would you like to apply for a Affordable Childcare Benefit?*

YesNo
*The forms will be sent to you via email upon submission of the form!

*The Government of British Columbia does not apply the Affordable Childcare Benefit during the December and March break. Fees during these time will not be reduced for the full amount.
1. Conditions of Registration

Please check the following
We have read Highroad Children’s Centre Handbook and fully understand the commitment we are making. We agree to abide by the rules of conduct of the Centre as outlined therein.*

Agree
We have enclosed a copy of the student’s birth certificate and, if needed, the appropriate documents in regard to citizenship status.*

Agree
Upload Birth Certificate*

Cancelof
We have indicated if our child is immunized*

YesNoDon't KnowPartially
We are aware that monthly payments are due on the fifth of each month. These payments must be made by pre-authorized debit or credit card.*

Agree
We agree to give one months notice if we with withdraw our child(ren). In the event that a child is withdrawn without notice, you agree to still be charged one months fees.*

Agree
2. Verification
We certify that the above information is true and accurate to the best of our knowledge. We agree with and commit to abide by the information laid out in this application, including the parent commitment. We hereby authorize Highroad Academy to verify all information provided, including but not limited to financial, criminal, medical, and scholastic information. We further authorize any previous Centres our child attended to release any pertinent information requested by Highroad Academy.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
3. Parent Commitment

Both parents/guardians must sign at the end of the section.
Spiritual and Moral Atmosphere: We recognize the vital and important role that parents, and the home fulfill in providing a foundation for the success of our child. We understand and respect the Christian morals and values that Highroad Children’s Centre, under the leadership of City Life Church, seeks to instill and reinforce in our children’s lives. We understand that Highroad Children’s Centre does not tolerate profanity, obscenity in word or action, or disrespect to the staff and leaders of the Centre. The Centre’s conviction is that the Bible is the final authority on all matters of life. We recognize and support the spiritual atmosphere that the Centre’s administration seeks to maintain.*

Agree
Centre Discipline: We agree to support the Centre policies and regulations and authorize the staff to employ discipline as they deem just, wise and expedient for the training of my child. We understand that the Centre reserves the right, after parental conference, to dismiss any child who fails to comply with the established regulations and discipline or whose parents do not assume their responsibilities to Highroad Children’s Centre.*

Agree
Centre Discipline: We agree to support the Centre policies and regulations and authorize the staff to employ discipline as they deem just, wise and expedient for the training of my child. We understand that the Centre reserves the right, after parental conference, to dismiss any child who fails to comply with the established regulations and discipline or whose parents do not assume their responsibilities to Highroad Children’s Centre.*

Agree
Financial Responsibility: We commit to assume our scriptural and contractual responsibility to financially support the Centre by paying all tuition and other fees in a timely manner*

Agree
Signature*

Clear
Date*

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date

Highroad Children's Centre

Disclosure of Personal Information
This information is required in order to register your child at this Centre. It will also allow the school to respond immediately to an emergency. For more information, the privacy officer for Highroad children’s Centre is Denise Kraubner, who may be reached at 604-792-4680.
Highroad Children’s Centre acknowledges that there will be no disclosure of personalinformation to unauthorized personnel or third parties who are not directly involved inHighroad Academy school management or the care, supervision and instruction of your child(ren) at this Centre, unless written authorization from a parent or legal guardian is provided to the Centre. The Centre or school will securely store all digital and hard copy parent and student personal information.

1. I consent to having Highroad Children’s Centre collect personal information that may include, birth certificate, legal guardianship, court order if applicable, parents’ work numbers and email address, behavioral, developmental and health information, emergency contact name and number, doctor’s name and number, health insurance number and any similar information needed for registration. I further consent to the use and disclosure of the information contained in this form and otherwise collected by or on behalf of Highroad Children’s Centre

(1) for the purpose of establishing, maintaining, and terminating the students and parents' relationship with Highroad Children’s Centre,

(2) for additional purposes identified when or before personal information is collected, and

(3) as otherwise provided in Highroad Academy’s Personal Information Privacy Policy, a copy of which is available on request. I also consent to the collection, use and disclosure of such personal information by and to agents, contractors, Highroad Academy’s website and service providers of Highroad Academy.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
2. I consent to photographs and work samples of my child(ren) used by HighroadAcademy or Highroad Children’s Centre in the yearbook, newsletters and otherpromotional material.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Highroad Children's Centre

Emergency Consent Card
Child's Name*

First NameMiddle NameLast Name
Birthdate*

MonthDayYear
Date
Child lives with*
Parent/Guardian Name *

First NameMiddle NameLast Name
Primary Number*
Please enter a valid phone number.
Secondary Number
Please enter a valid phone number.
Email*
example@example.com
Parent/Guardian Name

First NameMiddle NameLast Name
Primary Number
Please enter a valid phone number.
Secondary Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contacts

Your emergency contacts will only be contacted if we can't get ahold of parents first. Please make them aware they may be contacted to pick up in that event.
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Out of Province Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
I authorize the following people to pick up my child/ren from the Preschool facility:
Contact 1*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Contact 2

First NameLast Name
Relationship
First Name
Phone Number
Please enter a valid phone number.
Contact 3

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Medical Information
Child's Doctor*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Allergies/Intolerances*
Medications*
Personal health number*
Date effective*

MonthDayYear
Date
Please include a recent photo of your child in the event of an emergency*

Yes I have
Picture of Child*

Cancelof
I hereby give consent for my child child name* field. When ill to be taken to the nearest emergency centre by emergency vehicle when I cannot be contacted. Any associated costs incurred as a result of emergency transportation or medical treatment for the child are the responsibility of the child's parent/guardianI hereby give consent for my child child name* to receive medical treatment
It is the policy of Highroad Children’s Centre to notify a parent when a child is ill or needs medical attention. Occasionally we cannot contact parents and we need to get immediate help for the child. Our procedure is to ensure that the child is taken to the nearest emergency service. Please sign the consent below so that facility staff can take appropriate action on behalf of your child. Return the signed consent to the preschool immediately. This consent will accompany the child to the emergency centre.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Highroad Children's Centre

Office Use Section

Welcome to the Highroad Children's Centre online registration

1. Student Information

2. Parent/Guardian:

3. Parent/Guardian:

4. Additional Information

Emergency Contacts

I authorize the following people to pick up my child/ren from the Preschool facility:

3. Personal Information

1. Conditions of Registration

2. Verification

3. Parent Commitment

Highroad Children's Centre

Highroad Children's Centre

Emergency Contacts

I authorize the following people to pick up my child/ren from the Preschool facility:

Medical Information