THE NORTHEAST MISSISSIPPI COMMUNITY COLLEGE CHILD CARE CENTER APPLICATION

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1 Date Received THE NORTHEAST MISSISSIPPI COMMUNITY COLLEGE CHILD CARE CENTER APPLICATION Classification Schedule A. Student Full-time M-F (Full-time 12 hrs.) B. Faculty/Staff Part-time M-TH MW TTH CHILD REGISTRATION FORM Child s Name D.O.B. Address City State Zip Home Phone Mother s Name S. S.# Mother s Work Place Wk Phone Mother s Father s Name S.S. # Father s Work Place Wk Phone Father s Marital Status of Parent(s) married single divorced Custody and /or Visitation Arrangements: Step Parents Wk Phone Brothers Ages Sisters Ages Others living in the home: Relation Has child had previous day care placement? Where? Reason for requesting placement?

2 DEVELOPMENTAL HISTORY Personal History Type of Birth Normal Premature Any Complications Age he or she began Crawling Walking Is he or she a good climber? Does he or she fall easily? Age he or she began talking Does he or she speak in words? Or sentences? Does he or she have any difficulty in speaking? Other language Special words to describe his or her needs Child s Health History Chicken pox No Yes, at age Complications Measles No Yes, at age Complications Scarlet fever No Yes, at age Complications Hepatitis No Yes, at age Complications Diabetes No Yes, at age Complications Other at age Complications Frequent colds No Yes Why Runs fever easy No Yes Why Seizures (any) No Yes Why Allergic to Why Surgeries Why Braces or corrective shoes No Yes Why Illness or Disease that would harm a teacher or another child that you Are aware of: No Yes Explain Other comments: Eating Is child hungry at mealtime? Between meals? What are his or her favorite foods? What foods are refused? What eating problems does the child have? Does he or she eat with a spoon? Fork? Hands?

3 Toilet Habits Can the child be relied upon to indicate his or her bathroom wishes? What word is used for urination? For bowel movement? Does the child need to go more frequently than usual for his age? Is he or she frightened of the bathroom? Does the child need help with toileting? Was the child easy or difficult to train? Does the child wet his or her bed at night? How often? Sleeping What time does the child go to bed? Awaken? Is he or she ready for bed? Does he or she have his or her own room? Own bed? What does he or she take to bed with him or her? What is his or her mood on awakening? Does he or she take naps? (From when to when ) Social Relationships Has the child had experience in playing with other children? By nature, is he or she friendly? Aggressive? Shy? or Withdrawn? How does he or she get along with his brothers and sisters? Other adults? With what age children does he or she prefer to play? Does he or she know any children in the center or daycare home? Do you feel he or she will adjust easily to the day care situation? Does he or she enjoy being alone? How does the child relate to strangers? Does the child demand a lot of attention? What makes the child mad or upset? How does he or she show his or her feelings? What do you find is the best way of handling him or her? Are they frightened of the following: Animals? People? Rough Children? Loud Noises? Dark? Anything Else?

4 Favorite toys and activities at home Does he or she like to be read to? Listen to music? Does he or she prefer to play outside? Can he or she ride a tricycle? Has he or she had experience with: Clay? Scissors? Easel Painting? Finger Painting? Blocks? Water Play? Describe the type of discipline you use at home and how child reacts: time out spanking remove toys remove T.V. other Comments In what particular ways can we help your child this year? Describe your child briefly (Physical appearance, personality, abilities) Return application and forms to: Early Childhood Education Technology Northeast Mississippi Community College 101 Cunningham Boulevard Booneville, MS For more information contact:

5 PERMISSION FOR PARTICIPATION IN PLAY/ACTIVITIES I, hereby give my permission for To use all play equipment (inside and outside), to participate in all school activities, and to leave the center with teacher supervision for neighborhood walks and/or field trips taken in an authorized center vehicle. I assume all risks and hazards incidental to the conduct of the activity and transportation to an from the activity site. I do further hereby release and hold harmless Northeast Mississippi Community College, the sponsors, the supervisors, and/or all of them from any and all claims of injury and/or claims arising from participation in any activity. In case of injury to my child, I likewise waive any claims for damages that I might have against the above mentioned and likewise waive any claims against any person transporting my child to and from activities. In case of an accident or illness, I hereby authorize a representative of the NEMCC Child Care Center or the college to use his/her judgment in obtaining immediate medical are. CHILD S NAME PARENT S SIGNATURE DATE PHOTO PERMISSION I, give my permission for my child, To be photographed by the center during activities or special events ( these may be posted inside the center or published in the newspaper). CHILD S NAME PARENT S SIGNATURE DATE

6 PERMISSION FOR MEDICAL TREATMENT I, hereby give my permission for To be treated at NEMCC Child Care Center, for minor bumps, cuts, bruises. I also give permission to NEMCC Child Care Center, to transport my child to the hospital or have him/her transported by ambulance for a serious medical emergency. I understand that the following steps will include, but not limited to the following: 1) Attempt to contact parent or family member or child s doctor 2) Attempt to contact persons on emergency information form 3) If no contact is made, call 911 and transport with teacher 4) **if serious accident, 911 is called first, then parents, etc 5) expenses incurred will be parent s responsibility 6) NEMCC Child Care Center is not responsible for accidents that occur due to false information given at time of enrollment. 7) NEMCC Child Care Center will not assume responsibility for a child who is dropped off at the front door and/or is not signed in upon arrival. 8) NEMCC Child Care Center will not assume responsibility for a child once they are signed out for the day. 9) Other: PARENT S SIGNATURE DATE

7 NORTHEAST MISSISSIPPI COMMUNITY COLLEGE CHILD CARE CENTER MAJOR MEDICAL RELEASE CHILD S NAME D.O.B. The undersigned parent or legal guardian of the above named child, hereby authorize the NEMCC Child Care Center, into whose care the above named minor has been entrusted, in the event of my absence, do consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor under the care of general physician, surgeon, or dentist. The undersigned further authorize the NEMCC Child Care Center, to have the above named minor released into the custody of its representative, should hospital care no longer be required. Doctor s name Phone Insurance company Group # Name of Insured I.D. # Medicaid # Other information important to the care of your child such as allergies, heart conditions, medical conditions, etc Parent s signature date Witness of signature date

8 NEMCC CHILD CARE CENTER AUTHORIZATION TO PICK-UP AND EMERGENCY CONTACTS The names listed below have my permission to pick-up my child when I am unable to do so, or if I cannot be reached in the event of an emergency. I understand that I will not be called if any of the people listed below arrive to pick-up my child. I understand that I will only be contacted if someone other than those listed below show up to pick-up my child. I understand that my child will not be released to anyone not listed below unless I have verbally spoken with a staff member or dropped off a hand written note to my child s teacher. I also understand that I cannot prevent my child s birth father/mother to pick-up my child unless I furnish the center with court documents that states the visitation agreement. I also understand that the center may have to release my child to a birth parent if he/she provides appropriate court documentation and/or legal representation. Name relation to child Work phone Home phone Name relation to child Work phone Home phone Name relation to child Work phone Home phone Name relation to child Work phone Home phone YOU MUST LIST AT LEAST THREE CONTACTS. PARENT S SIGNATURE DATE Return application and forms to: Early Childhood Education Technology Northeast Mississippi Community College 101 Cunningham Boulevard Booneville, MS 38829

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