AFTER SCHOOL PROGRAM CHILD'S FACE SHEET/ENROLLMENT FORM

Transcription

1 CHILD'S FACE SHEET/ENROLLMENT FORM CHILD INFORMATION Child's Name: Date of Birth: Home Address: Telephone: School attending for 2014/15 school year: Primary Language: Child's Identifying Information (required by the Department of Early Education and Care): Eye Color: Hair Color: Sex: Height: Weight: Skin Color: Identifying Marks: PARENT/GUARDIAN INFORMATION Parent/Guardian Name: Relationship to Child: Home Address: Home Telephone: Mobile Phone: Preferred Secondary Work Name/Address: Work Telephone: Hours at Work: From: To: Parent/Guardian Name: Relationship to Child: Home Address: Home Telephone: Mobile Phone: Preferred Secondary Work Name/Address : Work Telephone: Hours at Work: From: To: CHILD'S PHYSICIAN & MEDICAL INFORMATION Physician Name: Telephone Number: Address: Fax Number: Allergies/Special Diet: Yes No (If yes, explain) Individual Health Plan for child with a chronic health condition? Yes No (if yes, please attach) Copies of any custody agreements, court orders, and restraining orders pertaining to the child? Yes No (if yes, please attach). Special Limitations or Concerns: Yes No (If yes, explain) 2014/2015 School: School Address: School Phone: 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 FOR WCCC USE: Date of Admission: Age at Admission: Site: 1

2 HEALTH CARE, EVACUATION, & PARENT HANDBOOK/POLICIES CONSENT FORM Child s Name Date of Birth Parent/Guardian Name Reachable Phone Parent/Guardian Name Reachable Phone FIRST AID AUTHORIZATION I authorize WCCC teachers who are trained in the basics of first aid/cpr to give my child first aid/cpr when appropriate. EMERGENCY MEDICAL CARE I understand that every effort will be made to contact me in the event of an emergency requiring medical treatment, including but not limited to an epinephrine auto-injection for suspected exposure to a life threatening allergen for my child when delay would be dangerous to the health of my child. 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. Physician Name Address Phone Number Health Insurance Coverage: Policy # Child s Allergies Chronic Health conditions EMERGENCY EVACUATION In the case of a catastrophic emergency, I give WCCC permission to transport my child by reasonable means to a location deemed appropriate by WCCC, Town of Wellesley police or fire departments or Wellesley College campus police. I understand I will be notified as soon as possible. PARENT HANDBOOK/POLICIES AGREEMENT I am aware that the WCCC Parent Handbook/Policies are located on the WCCC website After School Policies page, and acknowledge that I am responsible for knowing the contents. The link can be found at: After School Policies Tab Parent/Guardian Signature Date 2

3 PICK UP CONSENT FORM Child s Name PICK UP LIST (in order to be contacted in the case of an emergency) We must have written authorization from you to allow another person to pick up your child. We cannot accept phone calls for pick-up authorization. It is our policy to request photo identification from anyone unfamiliar to us. Please inform those on your pick-up list that we must have proper photo identification in order to release your child. I give permission for the following people to pick up my child from WCCC in an emergency or when I notify the program: 1. Name Physical Description 2. Name Physical Description 3. Name Physical Description 4. Name Physical Description 5. Name Physical Description Parent/Guardian Signature Date 3

4 TRANSPORTATION, OFF SITE, FIELD TRIP & PLAYGROUND CONSENT FORM Child s Name: Please check the appropriate line for how your child will arrive/depart from the program. Please note that all children grades 1-8 will arrive to the program via Unsupervised walk from his/her classroom My child will arrive at the program by: Supervised walk from his/her classroom Unsupervised walk from his/her classroom Program bus or van My child will depart from the program by: Parent pick-up By an authorized adult from my pick-up list Emergency Contact OFF-SITE ACTIVITIES PERMISSION I give permission for my child to participate in all of the regularly scheduled on-going activities located at the following off-site facilities: Wellesley Public Libraries Boulder Brook Reservation Babson College The Brook Path Wellesley Fire Stations Wellesley Duck Pond Linden St. Shops & Restaurant WCCC Early Childhood Program Wellesley College Wellesley Fells Area Forest St. Restaurants Lower Falls Area Wellesley Police Station Kelly Memorial Park Warren School Playground Longfellow Pond Area Dana Hall School The Wok Restaurant Tenacre Country Day School Cedar Street Playground All Wellesley Public Schools Wellesley Downtown Area Shops FIELD TRIP PERMISSION You have my permission to take my child on trips that the Wellesley Community Children s Center plans. I understand that I will be notified in writing of all trips requiring transportation in advance. I also understand that all necessary precautions will be taken to ensure his or her safety, and I will not hold the Wellesley Community Children s Center responsible for any accident, which may occur on such a trip. PLAYGROUND ACTIVITIES INFORMATION Almost daily, children enrolled in WCCC s After School programs play on the school playgrounds. At one point our licensor asked about playground supervision. We want you to know that we are happy to see children playing both with friends enrolled in our programs as well as friends from the neighborhood. WCCC teachers supervise your children, but they are not responsible for the play of those not in our care. While it might seem obvious, we are informing you of our policy that, while playing on the playground during after school hours at WCCC, we require children in our care to follow both rules established by the schools and WCCC regarding playground use. Parent/Guardian Signature: Date: 4

5 PERMISSION CONSENT FORM Child s Name: PHOTO PERMISSION Throughout the year various newspapers and magazines ask to photograph the children while they are at After School. Pictures might include walks, parties, or a child playing indoors or outside. Please check below. I give permission for my child to be photographed while attending the WCCC After School Program. I do not wish my child to be photographed while attending the WCCC After School Program OBSERVER PERMISSION WCCC hosts observers throughout the year from other children s centers, colleges, high schools, and the community, as well as our own consultants. The Massachusetts Department of Early Education and Care requires that parents sign a general consent form to indicate their awareness that observers are permitted at the After School Program sites. Observers are scheduled by the Director so as not to interfere with the children s program and general after school program routines. Observers may not interact with any child unless special consent from parents is obtained in writing and a detailed description of the interaction is furnished to parents , ADDRESS & PHONE LIST PERMISSION Each year WCCC distributes a list of family addresses and phone numbers to families currently enrolled at WCCC's After School Program. Please check below: I want to be included in WCCC's list of families. I do not want to be included in WCCC's list of families WEBSITE PERMISSION The WCCC website includes some photographs of children at play. The children are not identified by name, age or classroom. Photographs will be shown to parents before they are mounted on the site. I give permission for my child s photograph to be used on the WCCC website. I do not wish my child s photograph to be used on the WCCC website. Parent/Guardian Signature 5 Date

6 ORAL HEALTH PARTICIPATION CONSENT FORM Child s Name: In January 2010, EEC issued new regulations for child care programs that include a requirement that educators assist children with brushing their teeth if children are in care for more than four hours or if children have a meal while in care [606 CMR 7.11(11)(d]. This regulation is intended to: Help children learn about the importance of good oral health Provide information and resources regarding good oral health to child care programs and families Help address the high incidence of tooth decay among young children in Massachusetts, which is associated with numerous health risks. EEC licensed programs must comply with this regulation. However, parents may choose that their child (ren) not participate in tooth brushing while present at the childcare program. Please check one of the following: I do not wish to have my child participate in tooth brushing while in care at Wellesley Community Children s Center After School Program. I would like to have my child participate in tooth brushing while in care at Wellesley Community Children s Center After School Program. Parent Signature: Date: 6