EARLY LEARNING RESEARCH ACADEMY Infant and Toddlers Program. Enrollment Application

Transcription

1 Cmmunity Leadership Center 501 Cper Street Camden New Jersey, Phne: Fax: clc.camden.rutgers.edu EARLY LEARNING RESEARCH ACADEMY Infant and Tddlers Prgram Enrllment Applicatin CHILD (REN) S NAME BIRTH DATE: AGE GENDER M/F PRIMARY LANGUAGE SPOKEN AT HOME CURRENT/PROVIDER (IF ANY) FATHER S NAME: MOTHER S NAME: Father s cuntry f rigin: Mther s cuntry f rigin: Wh des yur child live with? Mther and father Mther Father Student (s) Address: Telephne Numbers: (H) (W) (Cell) Grandparents Other: (please specify) Student (s) Live with: (Please check all that applies) Mther and father Mther Father Grandparent Guardian (Specify: ) 1 P a g e

2 D yu currently have a Sibling (s) attending LEAP Academy University Charter Schl and/r the Rutgers Early Childhd Prgram? Yes N If Yes fr LEAP, If Yes fr Rutgers Pre-Schl Name (s) Grade (s) Age Name (s) Age Child s Dctr Telephne Address Persns authrized t pick up yur child and/r cntact in case f emergency if neither parent is available t assume respnsibility fr the child Name Phne Address Relatinship Name Phne Address Relatinship 2 P a g e

3 MEDICAL DECLARATION STATEMENT FOR SCHOOL-AGE CHILD CARE Child s Name: Date f Birth: Grade in September: Is yur child under any medical/physical restrictins? Yes N If yes, check all that apply? Asthma Hearing Lss Diabetes Cnvulsins Others: Is yur child been under a dctr s care r hspitalized within the last three years? Yes N If yes, please list: Is yur child allergic t any medicatins/fds/insect stings? Yes N If yes, please list: Family Dctr s Name: Telephne Number: ( ) Address: As a parent/guardian f the abve participating child, I certify that he/she is in gd physical health, has n special needs, and may participate in all f the activities f the Center s prgram, except as nted abve. 3 P a g e Parent s Signature: Date:

4 PERSONAL INFORMATION RECORD FOR INFANT/ TODDLER Child s name: Age: 1. What is yur child s current daily sleeping schedule? Mrning wake-up time: Evening bedtime: Daily naps: 2. Is yur child sleeping thrugh the night? If nt, when des child usually wake up at night? 3. What upsets r frightens yur child? 4. What des yur child find sthing r cmfrtable? 5. Hw is yur child nw reacting t strangers? 6. Is yur child using a cup, bttle r bth? 7. What are the times yur child is nw receiving the bttle each day? 8. Give the number f unces yur child is nw taking at each bttle feeding. 9. Is yur child taking frmula, whle milk, skim milk r ther? 10. Give any special instructins fr preparing frmula, if any. 11. Are there any ther special instructins cncerning bttle feeding yur child? 12. Is yur Child nw n baby fd r table fd? 4 P a g e

5 13. List fds yur child is nw eating Vegetables Fruits Meats Juices Breads 14. Is yur child nw eating finger fds? If yes, please list. 15. List any ther fds yur child is nw eating 16. Where des yur Child spend his /her waking hurs? (Cribs, Playpen, Crawling n the flr, etc) 17. What tys and activities make him/ her happy? 18. When des yur child usually have bwel mvements? 19. Has yur child begun ptty training? if yes describe his/her rutine. 20. What des yur child call his/her Bwel mvement: Urinatin: This space fr any ther infrmatin yu wish t share abut yur child. Parent s Signature: Date: 5 P a g e

6 EMEREGENCY CONTACT LIST Child s Name: Mther s Name: Wrk: Ext: Wrk Place: Father s Name: Wrk: Ext: Wrk Place: EMERGENCY CONTACT #1 Name: Wrk: Ext: EMERGENCY CONTACT #2 Name: Wrk: Ext: 10: infrmatin t Parents dcument Must be distributed t parents f every enrlled child and t all staff members The center may call the Bureau f Licensing fr a Spanish translatin f this dcument. 6 P a g e