BAS Enrollment Form

1Program & Start Date

Pick your child's grade level (fees update automatically) and the date you'd like care to begin.

Grade Level *

Desired Start Date *

2Child Information

Child's Photo (optional — will be placed in the registration form)

Choose Photo

JPG or PNG up to 10 MB

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

First Language

Other Languages

Home Address *

Postal Code *

3Medical & Health

Please attach an immunization record in Section 8 below.

Care Card / MSP Number *

Family Doctor / Clinic / Urgent Care

Doctor Phone

Last Tetanus Shot Date

Dentist (Optional) + Phone

Allergies / Medications (note any nut allergies)

Did your child have chickenpox at 12 months of age or older?

Yes No Not sure

4Custody & Medical Conditions

Is there a custody or guardianship agreement for this child?

Yes (please upload the legal agreement) No

Does your child have any of the following?

Asthma Seizure History Medical Condition Special Diet / Food Restrictions

If yes, please provide details

Medications (if applicable)

Medication	Reason	Time Given

5Development & Support

Helps us prepare to support your child. All answers are confidential and used only by program staff.

Support worker at school?

Yes No

Communication challenges?

Yes No

Social / emotional / behavioral challenges?

Yes No

Safety concerns?

Yes No

If yes to any above, please provide details

Strategies that help your child succeed

Additional comments (optional)

6Parent / Guardian Contacts

Parent 1 receives the confirmation email and acts as the primary contact.

Parent 1 Name *

Relationship to Child

Parent 1 Phone *

Parent 1 Email *

Parent 2 (optional)

Parent 2 Name

Relationship to Child

Parent 2 Phone

Parent 2 Email

7Emergency Contacts

Two people we can call if neither parent/guardian is reachable. Must be different from Parent 1 and Parent 2 above.

Contact 1 Name *

Contact 1 Phone *

Contact 2 Name

Contact 2 Phone

8Document Uploads

Required: a copy of your child's immunization record. PDF / JPG / PNG only, up to 10 MB.

Immunization Record *

Choose File

PDF / JPG / PNG up to 10 MB

9Fee Structure & Acknowledgment

Fees include Pro-D Days and Early Dismissal Days. Final parent portion may be lower depending on ACCB eligibility.

Program Fee	-
Less: CCFRI Subsidy	-
Parent Portion (per month, before ACCB)	-
Annual Registration Fee (one-time, non-refundable)	$35.00

Payment options: cash/cheque at head office (110-7580 River Road, Richmond), e-Transfer to cook@ccssociety.ca, or credit card (3% processing fee). All payments due at least 3 business days before start date.

I understand the fee structure above, including the $35 annual non-refundable registration fee, and that my final parent portion will be confirmed by staff based on ACCB eligibility.

10Emergency Medical Authorization

If a parent / guardian cannot be reached in an emergency, I authorize childcare staff to seek emergency medical care for my child and to call emergency medical services if necessary.

11Behavior Expectations Waiver

Please discuss the following rules with your child and sign together.

Respect

我們互相尊重

We are respectful of ourselves and other people. We are respectful of other people's ideas and feelings. We are respectful of the environment, equipment, and materials in the classroom and outside.

Safe

我們確保有一個安全的學習環境

We work and play safely to help keep ourselves and others from getting hurt.

Responsible

我們勉於承担責任

We take responsibility for our actions and our words. We treat others as we want to be treated. When we make a mistake, we are accountable for our errors, rather than making excuses.

If your child is a risk to themselves or others, parents will be contacted immediately for early pick-up. A behavior support plan may need to be created before the child returns. If risky behavior persists, the child may require additional support (such as a one-on-one worker). In extreme circumstances, the child may not be able to participate in the program.

I have discussed these rules with my child.

Child's printed name *

Parent typed signature *

Date

12Parent / Guardian Agreement

Tap each clause to read the full text. Add your initials and tick the acknowledgment to continue.

I understand that there is a non-refundable $35 annual registration fee per child / per school year, payable at the time of registration.
My child(ren)'s monthly childcare fees shall be paid by: (a) cash or cheque at the head office, 110-7580 River Road, Richmond, BC V6X 1X6; (b) e-Transfer to cook@ccssociety.ca; or (c) credit card (with a 3% processing fee; invoice issued monthly with a secure payment link).
All payments must be completed at least three (3) business days prior to the program start date.
Dates for school closure (Winter, Spring, and Summer Break) will be communicated separately and must be paid in advance.
A $35 charge will apply for any rejected or returned payments.
The program does not issue credits or refunds for absences due to sick days, vacation days, or unexpected program closures (e.g., strike days, snow days, power outages, natural disasters, or other circumstances beyond CCSS's control).

I confirm that I have completed and will keep updating the following:

Registration & Health Form
Emergency / Field Trip Consent Card
Immunization Record

I will provide supporting documentation for any individuals legally restricted from access or contact with my child under a Court Order / Separation Agreement.

Initial (Clauses 1-2)

I acknowledge and agree to clauses 1 and 2 above.

My child must be well enough to participate in all aspects of the program, including outdoor play.
I will notify staff immediately of any changes to my child's health and update records accordingly.
The program staff reserve the right to exclude my child if illness may compromise the health and safety of others, and may require written medical clearance from a physician before return.
CCSS staff are trained in the use of Epi-Pens for the treatment of emergency allergic reactions and are only authorized to administer medication to a child that requires specific chronic care or in emergency situations.

If my child poses a risk to themselves or others, I will be contacted immediately for early pick-up.
A behavior support plan may be required before my child returns.
Continued high-risk behavior may require additional support (e.g., a 1:1 worker). In extreme cases, participation in the program may be discontinued.

Parents / Guardians listed on the Emergency Consent Card must sign in and out when dropping off / picking up the child.
Written authorization must be provided if someone other than those listed on the Emergency Consent Card will pick up my child.
I will notify staff of any absence, including school activities (e.g., sports events).
Late pick-up after 6:00 pm will incur fees of $1 per minute (minimum $10 per occurrence).
If staff cannot reach me or emergency contacts within 30 minutes of closing, the Ministry of Children and Family Development Emergency Care Office will be contacted, in line with licensing regulations. Phone: 604-660-1044.

Initial (Clauses 3-5)

I acknowledge and agree to clauses 3, 4, and 5 above.

I understand and acknowledge that participation in CCSS programs involves certain risks. By enrolling my child, I agree to assume all such risks and any related financial responsibility. I release and hold harmless CCSS, its employees, and volunteers from any claims or liabilities arising from participation.

I understand that one month's written notice, given on or before the 1st of the month, is required to withdraw from the program. Cancellations with less than one month's notice are non-refundable.

Photos of my child may be taken for program documentation and internal use. Photos will not be used for external marketing or online purposes without separate, written parental consent (see the Photo Consent section below, which must also be completed).

Initial (Clauses 6-8)

I acknowledge and agree to clauses 6, 7, and 8 above.

I authorize my child to participate in all regular program activities, field trips, and arranged transportation. Parents are asked to provide daily snacks for their child. Please ensure all snacks are nut-free.

Parents / Guardians are required to use the Parent App as the primary method of communication with CKC Before & After School program staff. This includes, but is not limited to:

Reporting absences or late arrivals
Requesting early pick-up arrangements
Confirming authorized pick-up changes
General questions or program-related inquiries

Parents are also responsible for checking the Parent App regularly for important announcements and updates. I acknowledge that it is my responsibility to read and comply with program policies.

CCSS reserves the right to update policies and fees with reasonable notice to families.

Initial (Clauses 9-11)

I acknowledge and agree to clauses 9, 10, and 11 above.

13Photo & Video Consent

During the program, staff may capture photos of activities your child participates in. Please choose the level of consent you are most comfortable with.

A · Internal AND external use I consent to photos / videos of my child being taken and used for both internal purposes (Parent App, documentation, displays) and external purposes (newsletters, promotional or agency materials).

B · Internal use only I consent to photos being taken and used only for internal circulation within the school or program. Photos will not be used for external promotional or marketing materials.

C · Internal record-keeping only I consent that program staff may take photos of my child strictly for internal record-keeping, licensing compliance, incident reporting, or archival documentation. These photos will not be shared beyond program administration or CCSS management.

Your name *

Relationship to child

Typed signature *

Date

Contact info (phone or email)

14Final Confirmation & Signature

By submitting, you complete enrollment, waivers, and photo consent in a single step. A signed PDF copy will be emailed to you.

Type your full legal name *

Typing your name above serves as your electronic signature for this enrollment.

Date

I confirm that all information provided in this form is accurate and complete to the best of my knowledge. I will notify staff promptly of any changes (medical, contact, custody).

Cook Elementary BAS Program — Enrollment Form

1Program & Start Date

2Child Information

3Medical & Health

4Custody & Medical Conditions

5Development & Support

6Parent / Guardian Contacts

7Emergency Contacts

8Document Uploads

9Fee Structure & Acknowledgment

10Emergency Medical Authorization

11Behavior Expectations Waiver

Respect

Safe

Responsible

12Parent / Guardian Agreement

13Photo & Video Consent

14Final Confirmation & Signature

Executive Director / CEO