Registration Form
Please answer the following questions - we will keep your information confidential
start
 
What is the date today?

 
Which area do you most often attend programs?


 
Parent/Caregiver first name?

 
Parent/Caregiver last name?

 
Relationship to Child / Children?

 
What is your address?

 
Town?

 
Postal Code?

 
Phone # and/or email address

Used for program contact and newsletter
 
Would you like to receive emails regarding up-coming programs, events & information?

     
 
Will other people be bringing your child to programs? *

     
 
First Name of Caregiver 1

 
Last name of Caregiver 1

 
Relationship to Child / Children

 
Do you want to add another caregiver?

     
 
First name of Caregiver 2

 
Last name of Caregiver 2

 
Relationship to Child / Children

 
Do you want to add another caregiver?

 
Last name of Caregiver 3

 
First name of Caregiver 3

 
Relationship to Child / Children

 
Please add the names of your children

 
Child 1 First Name

 
Child 1 Last Name

 
Child 1 Age Group


 
Add another child?

     
 
Child 2 First Name

 
Child 2 Last Name

 
Child 2 Age Group


 
Add another child?

     
 
Child 3 First Name

 
Child 3 Last Name

 
Child 3 Age Group


 
Add another child?

     
 
Child 4 First Name

 
Child 4 Last Name

 
Child 4 Age Group


 
Add another child?

     
 
Child 5 First Name

 
Child 5 Last Name

 
Child 5 Age Group


 
Add another child?

     
 
Child 6 First Name

 
Child 6 Last Name

 
Child 6 Age Group


 
Media Release: Are you willing to allow Golden Prairie Parent Link Centre and/or local media to use photograph(s) of your child(ren) or yourself for promotional materials such as information brochures, website, handouts, and displays? *

     
 
Statistical Information

 
Are you an immigrant to Canada? *

     
 
Are your children immigrants? *

     
 
How long have you been in Canada


 
Are you First Nations, Metis or Inuit? *

     
 
Are your children First Nations, Metis or Inuit? *

     
 
When you fill out both the ASQ-3 & ASQ:SE-2 a $10 gift card will be mailed to you for each child.The ASQ-3 and ASQ:SE-2 are a series of questions that help parents track their child's general development in areas of communication, fine motor, gross motor, personal social & problem solving. After the questionnaire is completed, results will be sent to you by email, with attached play activities for you & your child so you can help your child reach their next set of milestones.

 
Are you interested in taking an Ages and Stages Questionnaire (ASQ) for your child / children?

     
Thank you.

Please visit our website or check us out on Facebook to find other programs in your area.

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