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WHO WE SERVE
SUPPORT FOR FAMILIES
SUPPORT FOR ELCCs IN ALBERTA
SUPPORT FOR ELCCs ACROSS CANADA
SUPPORT FOR FAMILIES
SUPPORT FOR ELCCs IN ALBERTA
SUPPORT FOR ELCCs ACROSS CANADA
OUR SERVICES
ALBERTA PROGRAMS
INCLUSION ASSESSMENT
PROFESSIONAL DEVELOPMENT
SUPPORT FOR PYRAMID MODEL INCLUSIVE PRACTICES
LEARNING SPACE FOR RENT
ALBERTA PROGRAMS
INCLUSION ASSESSMENT
PROFESSIONAL DEVELOPMENT
SUPPORT FOR PYRAMID MODEL INCLUSIVE PRACTICES
LEARNING SPACE FOR RENT
WHO WE ARE
ABOUT US
WHAT'S IN OUR NAME?
OUR TEAM
WORK FOR US
CONTACT US
ABOUT US
WHAT'S IN OUR NAME?
OUR TEAM
WORK FOR US
CONTACT US
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EARLY CHILDHOOD SERVICES

APPLICATION FORM

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TELL US ABOUT YOUR CHILD AND THEIR SUPPORT NETWORK

CHILD'S INFORMATION

Child's Legal First, Middle and Last Name (as stated on Birth Certificate)*

Child's Given Name (if different from above)

Child's Birth Date*

Year

Month

Day

Where Does Child Reside? (for example, with Mom, Dad, Grandparent or in hospital)*

Which Languages are Spoken at Home?*

If English is Not Your First Language, Would an Interpreter Be Helpful?

Yes

No

Is Your Child a Canadian Citizen?*

Yes

No

If You Wish to Declare That You Are an Aboriginal Person, Please Specify. (This Information is For Alberta Education.)

Métis

Non-Status Aboriginal

Inuit

Status Aboriginal, Band Member

PARENT/GUARDIAN #1 INFORMATION

Parent/Guardian #1: Full Name*

Parent/Guardian #1: Address*

City/Town and Province*

Postal Code*

Parent/Guardian #1: Cell Phone Number*

Parent/Guardian #1: Work or Home Phone Number

Parent/Guardian #1: Email*

PARENT/GUARDIAN #2 INFORMATION

Parent/Guardian #2: Full Name

Parent/Guardian #2: Address

City/Town and Province

Postal Code

Parent/Guardian #2: Cell Phone Number

Parent/Guardian #2: Work or Home Phone Number

Parent/Guardian #2: Email

ADDITIONAL SUPPORTS

Paediatrician

Child’s Paediatrician: Full Name

Child’s Paediatrician: Phone Number

Family Doctor

Family Doctor: Full Name

Family Doctor: Phone Number

Social Worker

Social Worker: Full Name

Social Worker: Phone Number

Social Worker: Email

Child Care Provider

Child Care Provider: Type

Daycare

Dayhome

Grandparent

Other

Child Care Provider: Name

Child Care Provider: Phone Number

Child Care Provider: Email

We acknowledge that Kids Included is located in Ward Anirniq, meaning 'Breath of Life' in Inuktun. Our provincial and national work takes us across lands of First Nations self government under modern treaty and unceded and unsurrendered territories from which First Nations, Metis and Inuit Peoples have been displaced. We recognize our privilege to work and live on this land as guests. This land, which holds the places where children live and play, represents our hope for a future where all feel a sense of belonging.

12852 - 141 Street NW
Edmonton, AB T5L 4N8

Phone: (780) 454-9910

Fax: (780) 455-1806

Email: info@kidsincluded.ca

Charitable registration number: 131527723RR0001

WHO WE SERVE
OUR SERVICES
WHO WE ARE
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