Back-Up Care Advantage Program Registration Materials

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1 Back-Up Care Advantage Program Registration Materials Dear Parent, Welcome to the Back-Up Care Advantage Program! An important part of preparing for a day of back-up care is ensuring that your care provider will have the information needed to prepare for a successful day with your child. Our centers are required to collect specific information and forms to meet state and local licensing requirements. The attached materials are designed to guide you through the process so all paperwork is ready when you need to use one of our back-up child care centers. These materials should be completed and submitted to your care provider on or before your first day of care. All shaded information is required for full registration. Some centers require that you sign center-specific consent forms. These will be provided on your first day of care. Be sure to keep a copy of these materials on hand should you decide to use additional centers. Because many state and local licensing authorities require that some information be updated at regular intervals, it is important to check with your provider before each visit to ensure that all materials are up-to-date. We re happy to work with you through the registration process. Please contact your preferred center-based care provider directly. We look forward to serving your family soon! The Back-Up Care Advantage Team

2 Back-Up Care Advantage Program Registration Checklist Child Name: Child Information Form Parent/Guardian Information Form (one for each parent/guardian in the family) Authorization for Release and Emergency Medical Treatment Authorized Non-Parent/Guardian Information Form Medical and Insurance Information Form Photograph of Child* (see below for photograph requirements) Photograph of Parent(s)/Guardian(s)* (see below for photograph requirements) Photograph(s) of Non-Parent/Guardian Authorized for Release* (see below for photograph requirements) Massachusetts - Physicians Statement (one for each child to be registered - form must be completed by the child's physician) Massachusetts - Child Enrollment Massachusetts - Developmental History Massachusetts - Emergency Card Massachusetts - Certificate of Immunization Massachusetts - First Aid & Emergency Medical Care Massachusetts - Off Site Activity

3 Back-Up Care Advantage Program Child Registration Information Child Name: Child Nickname: Child Date of Birth: ( / / ) (mm/dd/yyyy) Child Gender: Male (please circle) Female Child Lives With: Does your child have any allergies or food restrictions? yes no (please circle) If yes, please describe: Does your child have any diagnosed special needs or medical conditions? yes no (please circle) If yes, please describe: Are your child's activities restricted by any special needs, medical or other conditions? yes no (please circle) If yes, please describe: Are there any custody arrangements for your child? yes no (please circle) If yes, please describe: (A court order with supporting documentation describing custody arrangements and restrictions must be provided.) Regular Care Arrangements: Child's Primary Language: Sleeping Schedule: (for children under 36 months only) Toilet Schedule: (for children under 36 months only) Other Helpful Information: shaded information is required for full registration and use of a back-up child care program Center Staff Signature:

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5 Child Name: Back-Up Care Advantage Program Parent/Guardian Information Form Please provide information on the child's parent/guardian(s). If the child has more than 2 legal parent(s)/guardian(s) please complete additional Parent/Guardian Information Form to ensure that all legal parent/guardians are listed on the child's file. Parent/Guardian Information Parent/Guardian Name: Relation to Child: Employer (Company Name): Cell Phone Work Address Work Phone & Ext Home Address Home Contact Information Home Address Home Phone Work Contact Information (Required if applicable) Work Address Home City, State, Zip Work City, State, Zip Parent/Guardian Information Parent/Guardian Name: Relation to Child: Employer (Company Name): Cell Phone Work Address Work Phone & Ext Home Address Home Contact Information Home Address Home Phone Work Contact Information (Required if applicable) Work Address Home City, State, Zip Work City, State, Zip shaded information is required for full registration and use of a back-up child care program

6 Back-Up Care Advantage Program Parent/Guardian Authorization for Release of Child and Emergency Medical Treatment Child Name: Each child must have at least 1 person other than the child's parent(s) or guardian(s) authorized for release and 1 person authorized to make medical decisions in the event of an emergency. Parent/Guardian Authorization for Release of Child: I authorize center staff to contact and/or release my child to the following representative(s) designated by me for this purpose: Please provide contact information for authorized non-parent/guardians on the Authorized Non-Parent/Guardian Information Form Parent/Guardian Authorization for Emergency Medical Treatment: I understand that center staff is trained in basic f irst aid and CPR. I authorize center staff to administer first aid to my child for minor injuries or illnesses as appropriate and to notify me of any actions taken. For all other conditions requiring emergency medical treatment, center staff will attempt to contact me as the nature of the emergency permits. If I cannot be reached, I authorize center staff to contact the following representative(s) designated by me to act on my behalf for this purpose. If my representative cannot be reached, I authorize center staff to transport my child to a local hospital or other medical facility and obtain any necessary medical treatment at my expense. Please provide contact information for aut horized non-parent/guardians on the Authorized Non-Parent/ Guardian Information Form Center Staff Signature:

7 Back-Up Care Advantage Program Authorized Non-Parent/Guardian Information Form An authorized non-parent/guardian is someone other than the parent(s) or guardian(s) who is authorized to pick the child up and or make medical decisions for the child in the event of an emergency when the parent(s) or guardian(s) cannot be reached. Child Name: Each child must have at least 1 person other than the child's parent(s) or guardian(s) authorized for release and 1 person authorized to make medical decisions in the event of an emergency. Authorized Non-Parent/Guardian 1 Relationship to child: Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: Authorized for emergency medical decisions?: yes no (please circle) Authorized for release of child?: yes no (please circle) Authorized Non-Parent/Guardian 2 Relationship to child: Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: Authorized for emergency medica l decisions? : Authorized for release of child?: yes no (please circle) yes no (please circle) Authorized Non-Parent/Guardian 3 Relationship to child: Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: Authorized for emergency medical decisions?: Authorized for release of child?: yes no (please circle) yes no (please circle) Authorized Non-Parent/Guardian 4 Relationship to child: Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: Authorized for emergency medical decisions?: yes no (please circle) Authorized for release of child?: yes no (please circle) shaded information is required for full registration and use of a back-up child care program.

8 Back-Up Care Advantage Program Authorized Non-Parent/Guardian Information Form An authorized non-parent/guardian is someone other than the parent(s) or guardian(s) who is authorized to pick the child up and or make medical decisions for the child in the event of an emergency when the parent(s) or guardian(s) cannot be reached. Child Name: Each child must have at least 1 person other than the child's parent(s) or guardian(s) authorized for release and 1 person authorized to make medical decisions in the event of an emergency. Authorized Non-Parent/Guardian 1 Relationship to child: Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: Address City, State, Zip Authorized for emergency medical decisions?: Authorized for release of child?: yes no (please circle) yes no (please circle) Authorized Non-Parent/Guardian 2 Relationship to child: Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: Address City, State, Zip Authorized for emergency medical decisions?: Authorized for release of child?: yes no (please circle) yes no (please circle) Authorized Non-Parent/Guardian 3 Relationship to child: Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: Address City, State, Zip Authorized for emergency medical decisions?: Authorized for release of child?: yes no (please circle) yes no (please circle) shaded information is required for full registration and use of a back-up child care program.

9 Back-Up Care Advantage Program Medical, Dental and Insurance Information Child Name: Doctor Information Doctor/Clinic Name: Address Line 1 Doctor/Clinic Phone Address Line 2 Fax City, State, Zip Medical Insurance Information Medical Insurance Carrier: Membership ID #: Employer Providing Insurance: Member Services Phone ( ) - Hospital Information Affiliate/Preferred Hospital: Hospital Phone Dentist Information Dentist Name: Address Line 1 Dentist/Clinic Phone Address Line 2 Fax City, State, Zip Dental Insurance Information Dental Insurance Carrier: Membership ID #: Employer Providing Insurance: Member Services Phone shaded information is required for full registration and use of a back-up child care program. Center Staff Signature:

10 Back-Up Care Advantage Program Parent/Guardian Consents and Registration Agreement This page is only required for those families who will be attending a Bright Horizons center Child Name: Parent/Guardian Consents Parent/Guardian Consent to Leave the Premises I give permission for my child to leave the Center for exercise and educational purposes with Bright Horizons staff yes no (please circle) Parent/Guardian Consent for Photography/Video of Child or Parent/Guardian I give permission for my child to be photographed and videotaped for use by or on behalf of Bright Horizons for educational, training, curriculum, marketing and similar purposes. yes no (please circle) Registration Agreement I understand and agree to the following: 1. Completion of Registration; Information; Payments. Registration must be fully completed prior to my using the Center. I will notify Bright Horizons and update all medical, family and other information previously provided as part of the registration of my child. Medical, family and other information may be shared among Bright Horizons child care centers where necessary for registration. Additional registration information or materials may be needed to comply with local licensing requirements. Where applicable, all registration fees and/or per-use fees (co-payments) must be paid in connection with the registration of my child and use of the Center. 2. Parent Handbook; Policies and Procedures; Use of Center. I have received, reviewed and understand the Parent Handbook and related information concerning the Center and the backup child care services provided by Bright Horizons. I will use the Center in accordance with the terms of the Parent Handbook and Bright Horizons policies and procedures made available at the Center. Use of the Center and the backup child care services may be denied in the event I do not comply with the terms of this Agreement, or when determined by Bright Horizons to be in the best interests of my child or the children using the Center. The availability of the Center and the backup child care services are subject to change at any time. 3. No Employment. I will not solicit, employ or enter into any contract with any employee of Bright Horizons to perform child care or similar services under any circumstances without the express consent of Bright Horizons. If I employ or contract with any employee of Bright Horizons or person who within one year of the date of such employing or contracting was employed or under contract with Bright Horizons, I will pay Bright Horizons a placement fee of $5, Release of Bright Horizons. In consideration of the registration of my child, I release Bright Horizons Family Solutions, Inc., Bright Horizons Children s Centers, Inc., and their related companies, directors, officers, employees and agents, from any claims, losses, damages or costs (including attorneys fees) caused by or arising from my child s registration, use of the Center, or participation in the programs and activities conducted by Bright Horizons other than to the extent caused by the negligent or willful misconduct of Bright Horizons Family Solutions, Inc., Bright Horizons Children s Centers, Inc., and their related companies, directors, officers, employees and agents. 5. Release of Employer. My employer has engaged Bright Horizons to provide backup child care services as a convenience for my employer s employees and other participants. My employer is not responsible for the Center or the backup child care services provided by Bright Horizons. In consideration of the registration of my child, I release my employer, and its directors, officers, employees and agents, from any claims, losses, damages or costs (including attorneys fees) caused by or arising from my child s registration, use of the Center, or participation in the programs and activities conducted by Bright Horizons.

11 GROUP CHILD CARE AND SCHOOL AGE CHILD CARE CHILD'S ENROLLMENT FORM Program: Group Child Care: School Age Care: Child's Name: Eye Color: Skin Color: Home Address: Hair Color: Height: Telephone: Sex: Weight: Date of Admission: Age at Admission: Date of Birth: Primary Language: Identifying Marks: Allergies / special diets: PARENT/GUARDIAN INFORMATION: Parent/Guardian Name: Parent/Guardian Name: Relationship to child: Relationship to child: Home Address: Home Address: Home Telephone #: Home Telephone #: Bus. Name: Bus. Name: Bus. Address: Bus. Address: Bus. Telephone #: Bus. Telephone #: Hours at Work: Hours at Work: ADDITIONAL INFORMATION: Child's Physician/Clinic: Address: Phone: Chronic health conditions: Special limitations or concerns: SCHOOL AGE ONLY Current School: School Address: I certify that documentation of physical examination and immunizations in accordance with public school health requirements, and lead poisoning screening in accordance with public health requirements are on file at my child's school. Parent/Guardian initials: Parent/Guardian Signature Date ChildRecordCoversheetEnrollment

12 DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION Regulations for licensed child care facilities require this information to be on file to address the needs of children while in care. CHILD'S NAME DATE OF BIRTH *Note: Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child. DEVELOPMENTAL HISTORY Age began sitting crawling walking talking *Does your child pull up? *Crawl? *Walk with support? Any speech difficulties? Special words to describe needs Language spoken at home *Any history of colic? *Does your child use pacifier or suck thumb? *When? *Does your child have a fussy time? *When? *How do you handle this time? HEALTH Any known complications at birth? Serious illnesses and/or hospitalizations: Special physical conditions, disabilities: Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions: Regular medications: EATING HABITS Special characteristics or difficulties: *If infant is on a special formula, describe its preparation in detail Favorite foods: Foods refused: * Is your child fed held in lap? High chair? * Does your child eat with spoon? Fork? Hands? TOILET HABITS *Are disposable or cloth diapers used? *Is there a frequent occurrence of diaper rash? *Do you use: oil powder lotion other *Are bowel movements regular? how many per day? *Is there a problem with diarrhea? constipation? *Has toilet training been attempted? *Please describe any particular procedure to be used for your child at the center What is used at home? pottychair? special child seat? regular seat? How does your child indicate bathroom needs (include special words): Is your child ever reluctant to use the bathroom? Does the child have accidents? Page 1 of 2 GCCDevelopmentalHistotry

13 SLEEPING HABITS *Does your child sleep in a crib? Bed? Does your child become tired or nap during the day (include when and how long)?. Please note: The American Academy of Pediatrics has determined that placing a baby on his/her back to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and unexplained death of a baby under one year of age. If your child does not usually sleep on his/her back, please contact your pediatrician immediately to discuss the best sleeping position for your baby. Please also take the time to discuss your child s sleeping position with your caregiver When does your child go to bed at night? and get up in the morning? Describe any special characteristics or needs (stuffed animal, story, mood on walking etc) SOCIAL RELATIONSHIPS How would you describe your child: Previous experience with other children/day care: Reaction to strangers: Able to play alone: Favorite toys and activities: Fears (the dark, animals, etc): How do you comfort your child: What is the method of behavior management/discipline at home: What would you like your child to gain from this childcare experience? DAILY SCHEDULE: Please describe your child's schedule on a typical day. *For infants, please include awakening, eating, time out of crib/bed, napping, toilet habits, fussy time, night bedtime, etc. Is there anything else we should know about your child? Page 2 of 2 GCCDevelopmentalHistotry

14 Child's Name: Date of Birth: EMERGENCY CARD INFORMATION Child's Home Address: Phone: INSTRUCTIONS TO REACH PARENT/GUARDIAN 1. (Name, Address, Phone #) 2. (Name, Address, Phone #) PEDIATRICIAN OR SOURCE OF HEALTH CARE 1. (Doctor's Name, Address, Phone#) EMERGENCY CONTACT PERSON(S) 1. (Name, Address, Phone #) 2. (Name, Address, Phone #) MEDICAL EMERGENCY TREATMENT I hereby give (Name of program) permission to administer basic first aid and/or CPR to my child (Name) and/or take my child, to a hospital for medical (Name) treatment when I cannot be reached or when delay would be dangerous to my child's health. (Parent Signature) (Date) INSURANCE INFORMATION (OPTIONAL) Company Name: Policy # Participating Hospital: Special Instructions: GCCSACCEmergencyCardInformation

15 GROUP CHILD CARE AND SCHOOL AGE CHILD CARE FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM 102 CMR 7.09(3) Child's Name: Date of Birth: I authorize staff in the child care program who are trained in the basics of first aid to give my child first aid when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to, and to secure necessary medical treatment for my child. Child's Physician Name: Address: Phone Number: Child's Allergies: Chronic Health Conditions: Emergency Contacts (In order to be contacted) 1. Name: Address: Relationship to Child: Phone #: Do you give permission for child to be released to this person? Yes No 2. Name: Address: Relationship to Child: Phone #: Do you give permission for child to be released to this person? Yes No 3. Name: Address: Relationship to Child: Phone #: Do you give permission for child to be released to this person? Yes No Health Insurance Coverage: Policy #: Parent(s) Name: Phone(w) Phone (h) Parent(s) Name: Phone(w) Phone (h) Parent/Guardian Signature Date FirstAidEmergencyCareConsent

16 PROGRAM YEAR OFF-SITE ACTIVITIES PERMISSION FORM Section 7.34(5)(c) SACC Program: Address: CHILD'S NAME: I, give permission for my child to participate (Parent/Guardian's name) in all of the regularly scheduled on-going activities located at the following off-site facilities: The program will provide in writing a list of scheduled activities. (Parent/Guardian Signature) (Date) SACCOffSiteActivitiesPermission

17 Dear Physician: (Child's Name) is enrolled in an early childhood program licensed by the Department of Early Education and Care. The Department of Early Education and Care s regulations require at the time of admission a written statement from a physician as evidence of each child's annual physical examination, immunizations and lead screening in accordance with Department of Public Health's recommended schedules. A prompt response is appreciated. Evidence of a physical exam is valid for one year from the date the child was examined and must be renewed annually thereafter. IDENTIFICATION Name of Child: Date of Birth: Address: Phone # Name of Parents: Address: Date of Examination of Child: What is your opinion concerning the child's general health and appearance: Has this child been screened for lead poisoning? Yes No If Yes, date screened: Does this child have any disabilities or chronic medical problems (allergies, limited vision, etc.) which require special consideration or care by the child care provider? If so, please detail below: Physician's Signature: Comments: Please return to Program: GCCPhysicianStatment

18 Massachusetts Department of Public Health CERTIFICATE OF IMMUNIZATION Name: Date of Birth: Sex: 0 female o male If combination vaccine is administered, please indicate vaccine type (e.g., DTaP-Hib, etc.) Vaccine DateNaccine Type Vaccine DateNaccine Type Hepatitis B 1 Haemophilus 1 (e.g., HepB, HepB-Hib, influenzae type b (e.g., 2 OTaF'-HepB-IPV) Hib, HepB-Hib, DTaP Hib) Diphtheria, 1 Measles, Mumps, 1 Tetanus, Pertussis -. Rubella 2 (e.g., OTaP, DT, (MMR) 2 DTaP-Hib, 3 Varicella 1 OTaP-HepB-IPV, Td, (Var) 4 Tdap) 2 5 Meningococcal 1 6 Conjugate (MCV4) or Polysaccharide (MPSV4) 2 Polio 1 Hepatitis A 1 (eg,ipv, (HepA) 2 2 DTaP-HepB-IPV) 3 Pneumococcal 1.. _ Polysaccharide 4 2 (PPV23) 5 Influenza 1 Inactivated (Intramuscular) Pneumococcal 1 2 or Conjugate 2 Live (Intranasal) 3 (PCV7) 3 Other: 4 Serologic Proof of Immunity Check One Chickenpox History Test (ifdone) Date oftesl Positive Measles I I Mumps I I Rubella I. I Varicella' I I Hepatitis B I I, Must also check Chickenpox History box. Negative D Check the box if this person has a p~.ysician-certified reliable history of chickenpox. Reliable history may be based on: physician interpretation of parenuguardian description of chickenpox physical diagnosis of chickenpox, or serologic proof of immunity I certify that this immunization information was transferred from the above-named individual's medical records. Doctor or nurse's name (please print): Signature: Facility name: Certificate of Immunization June 2005

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