Registration Registering Your Child Please complete the form below to register. If you have any issues or questions please don’t hesitate to reach out to us. (825) 558-8078info@maxecs.netFill Out The Form Below To Register Your Child "*" indicates required fields Child's InformationChild's Full Name* First Middle Last Gender* Male Female *Gender as per birth certificateChild's Date of Birth*YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM123456789101112DD12345678910111213141516171819202122232425262728293031HiddenAge As Of August 31Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Parent / Guardian 1Name* First Last Email* Enter Email Confirm Email Primary Phone*Alternate PhoneAddress* Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Parent / Guardian 2Name First Last Email Enter Email Confirm Email Primary PhoneAlternate PhoneAddress Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Emergency Contact InformationEmergency Contact Name* First Last Relationship To Child* Primary Phone*Email* Enter Email Confirm Email Address* Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Person Who Has Permission To Pick Up Your ChildName First Last PhoneRelationship to Child Child's Medical InformationAlberta Health Care Number (FOIP)* My Child's Immunizations Are Up To Date* Yes No Allergies Has Your Child Had A Recent Vision Test? If So, Date? Has Your Child Had A Recent Hearing Test? If So, Date? Medical Conditions That MaxECS Staff Should Be Aware Of School / Children InformationSchool / Childcare My Child Will Attend In September For The 2024/2025 School Year* School Phone*School Email* Choose Days Child Attends School* Monday Tuesday Wednesday Thursday Friday Start Time* Hours : Minutes AM PM AM/PM End Time* Hours : Minutes AM PM AM/PM School Address* Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Teacher Name Director / Owner Name Referring Therapist Additional Information You Feel MaxECS Staff Should Know? Additional Concerns?Access To Funding Through Alberta Education:Please agree with each statement below.I am requesting MaxECS apply for Program Unit Funding (PUF) or Mild/Moderate funding (M/M) or English as an Additional Language (EAL) funding.* Agree To obtain PUF, M/M or EAL Funding I must sign this PUF / M/M application and provide a copy of my child's birth certificate (and documentation that supports my ability to work in Canada, if my child was not born in Canada).* Agree I consent to my child receiving assessment and services with therapists and individuals contracted by MaxECS. These may include Speech-Language Therapists, Occupational Therapists, Physiotherapists and/or Behaviour Strategists.* Agree I understand my child must be registered in and attend regularly a licensed early learning program to receive this funding. Lack of attendance in an educational setting will put my child's funding and program at risk for withdrawal from AB ED funding. Attendance for children requiring 475 program hours, I understand that my child must be registered and regularly attend a licensed early learning program, at least 2 days per week, with a minimum of 6 hours of teacher-directed instruction per week to receive this funding. Lack of attendance in an educational setting will jeopardize my child's funding and be a cause for withdrawal.* Agree I understand that my child may be required to participate in additional programming that is scheduled outside of the program time my child attends their community program to ensure that they meet Alberta Educations minimum hours.* Agree I will provide 24 hours notice to my therapist, if my child will miss their therapy session. I must let my therapists know if my child will be unable to attend a session. I will be allowed one no-show appointment; all others, I may be required to pay a $50 short notice cancellation fee if MaxECS incurs a charge due to the short notice cancellation/no show.* Agree I will notify my child's PUF / M/M Certificated Teacher if my child's therapist did not show to the scheduled therapy time.* Agree I understand that extended conversations with my child's therapist could result in a reduction of therapy hours. Additional interaction may be considered consultative in nature and may be billed, thus reducing your child's therapy hours.* Agree I will let my child's education assistant and teachers know if my child will be absent at preschool, childcare or kindergarten on any given day.* Agree I will provide one month's notice if I decide to withdraw my child from a therapy program.* Agree I understand that if I am not on time for my therapy session, my session time will be reduced accordingly. (Therapy time will not be extended).* Agree In the unfortunate event that my child becomes seriously ill and is absent for an extended period, I will provide a signed report from my child's doctor to be included with the attendance record for Alberta Education.* Agree PUF ONLY: I will attend 3 - 1 hour Individual Program Plan (IPP) meetings during the year. Time for the meeting will be limited to one hour per meeting and will be scheduled at a time mutually convenient for the team.* Agree I give permission to MaxECS to release records, assessments and therapy reports for my child to their receiving school.* Agree I give permission to MaxECS to share records, assessments and therapy reports for my child with other professional team members. (eg; speech language therapists, occupational therapists, physical therapists, physicians, pediatricians, etc)* Agree Required DocumentsCanadian Identification Documentation* YES - I am uploading a copy of my child’s Canadian identification documentation NO - I agree to provide my child's Canadian identification documentation by October 31 NOTE: Documentation must be provided to MaxECS admin by October 31, 2025I am uploading*Please make a selectionCanadian birth certificateCanadian passportCanadian citizenship documentationCanadian permanent resident card, both sidesValid Canadian visitor visaValid Canadian parental work visaPlease provide a copy of your child’s Canadian identification documentation*Max. file size: 300 MB.Please Date & SignName* First Last Signature*NameThis field is for validation purposes and should be left unchanged.
