School Year 2015/2016 BEFORE AND AFTER CARE MANDATORY FORMS

Transcription

1 School Year 2015/2016 BEFORE AND AFTER CARE MANDATORY FORMS Forms: 2015/2016 Enrollment Contract (2 pages).. Page 1 Emergency Form (2 pages) Page 3 Medication Authorization Form (2 pages) Page 5 OCC All About Form (2 pages). Page 7 Health Inventory (4 pages). Page 9 Publicity/Photography/Video Recording. Page 13 Transportation Permission Slip Page 14 Behavioral Management Plan (2 pages) Page 15 Referral Program... Page 17 Child Care Admin Booklet A Parent s Guide to Regulated Child Care Page 18 0

2 SCHOOL AGE CHILDCARE CENTER 2015/2016 ENROLLMENT CONTRACT Center: School Your Child Attends Date Completed Parent/Guardian Information (only parents or guardians who sign this form will have access to child information) Parent/Guardian 1 (Responsible Party) Relationship to child(ren): Name Signature: Address: City: State Zip Employer: Work Phone: Cell Phone: Home Phone: ** Parent/Guardian 2 ** information is required for billing and account management Relationship to child(ren): Name Signature: Address: City: State Zip Employer: Work Phone: Cell Phone: Home Phone: Other adults who have access to Child(ren) s information: Name: Relationship to child: Phone: Name: Relationship to child: Phone: (Only the parents/guardians and adults listed above will be given information about the care of the children listed below.) Children Information - List additional children on the back Child 1 Name: M/F (circle) Date of Birth: Age: Grade entering in school Child will attend: Before School on M T W Th F (circle all that apply) Date child will start care After School on M T W Th F (circle all that apply) Check here if this child will attend as a: Drop-in only Waiting lists may apply when enrollment reaches site capacity. At the time of registration, a $90.00 per family, nonrefundable registration fee is due (if after August 1, 2015 late registration fee is $125.00). Registrations received after June 15, 2015 must also pay first tuition payment at time of registration. 1. Do you receive any supplemental childcare benefits from any government agency? (Y/N) If yes, please indicate the name of the agency (ABC Care does accept a limited number of government-subsidized families in our programs. Upon receipt of application and registration fee, notice of confirmation in writing will be issued.) 2. Is your child receiving intervention services through the school? (Y/N) If yes, please provide copy of IEP/IFSP/504 Plan so Director is aware of modifications necessary (will remain confidential). I have read the Parent Manual and will abide by the information and policies set forth by ABC Care. I have received the booklet A Parent s Guide To Regulated Child Care, a guide written by the Child Care Administration. All disputes go to mediation prior to court. (Parent/Guardian s Signature) Revised 4/29/15 (Date) Page 1 Parent Contract 1

3 Page 2 Enrollment Contract: Additional Children (all children listed must be from the same home and family) Child 2 Name: M/F (circle) Date of Birth: Age: Grade entering in school Child will attend: Before School on M T W Th F (circle all that apply) Date child will start care After School on M T W Th F (circle all that apply) Check here if this child will attend as a: Drop-in only Child 3 Name: M/F (circle) Date of Birth: Age: Grade entering in school Child will attend: Before School on M T W Th F (circle all that apply) Date child will start care After School on M T W Th F (circle all that apply) Check here if this child will attend as a: Drop-in only ALL FAMILIES MUST EITHER PROVIDE CHECKING, SAVINGS, OR CREDIT CARD INFORMATION, REGARDLESS OF THE PAYMENT OPTION CHOSEN. PAYMENT OPTIONS We have three (3) great billing options: Option #1: The easiest method is for our customers to set up ACH withdrawals to be made directly from their bank account. (Due date is on or before 1 st of each month.) There will be no fees for this option. Option #2: Payment by check to be received on or before the first of each month. No fees involved. Option #3: Monthly recurring automatic credit card payments to be made 5 days prior to the 1st of each month. (Due date is the 1 st of each month). This procedure will be assessed a fee of 0.5%. (Example: $100 due x 0.5% = $100.50) Please complete the information below for recurring automatic payments: I authorize ABC Care, Inc. to charge my credit card or use ACH withdrawals (full name) indicated below 5 days prior to the due date for payment of my child care tuition. Billing Address City, State, Zip Phone# Checking Savings Name on Acct Visa MasterCard Cardholder Name Bank Name Account Number Account Number Exp. Date Bank Routing # CVV (3-digit number on back of card) Bank City/State SIGNATURE DATE This authorization will remain in effect until the end of the school year. I agree to notify ABC Care, Inc. in writing of any changes in my account information or termination of this authorization at least 30 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments will be executed on the next business day. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that ABC Care, Inc. may, at its discretion, attempt to process the charge again within 5 business days. An additional $30 charge for each attempt will be assessed as a separate transaction. I acknowledge ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form. Return completed enrollment contract to: ABC Care, Inc Patapsco Road Finksburg, MD Fax: abccare@abccareinc.com 2

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10 Information and Instructions for Parents/Guardians: REQUIRED INFORMATION MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care HEALTH INVENTORY The following information is required prior to a child attending a Maryland State Department of Education licensed, registered or approved child care or nursery school: A physical examination by a physician or certified nurse practitioner completed no more than twelve months prior to attending child care. A Physical Examination form designated by the Maryland State Department of Education and the Department of Health and Mental Hygiene shall be used to meet this requirement (See COMAR 13A , 13A and 13A ). Evidence of immunizations. A Maryland Immunization Certification form for newly enrolling children may be obtained from the local health department or from school personnel. The immunization certification form (DHMH 896) or a printed or a computer generated immunization record form and the required immunizations must be completed before a child may attend. This form can be found at: Evidence of Blood-Lead Testing for children living in designated at risk areas. The blood-lead testing certificate (DHMH 4620) (or another written document signed by a Health Care Practitioner) shall be used to meet this requirement. This form can be found at: EXEMPTIONS Exemptions from a physical examination, immunizations and Blood-Lead testing are permitted if the family has an objection based on their religious beliefs and practices. The Blood-Lead certificate must be signed by a Health Care Practitioner stating a questionnaire was done. Children may also be exempted from immunization requirements if a physician, nurse practitioner or health department official certifies that there is a medical reason for the child not to receive a vaccine. The health information on this form will be available only to those health and child care provider or child care personnel who have a legitimate care responsibility for your child. INSTRUCTIONS Please complete Part I of this Physical Examination form. Part II must be completed by a physician or nurse practitioner, or a copy of your child's physical examination must be attached to this form. If your child requires medication to be administered during child care hours, you must have the physician complete a Medication Authorization Form (OCC 1216) for each medication. The Medication Authorization Form can be obtained at CC A42/30754/1216_MedAuth_r pdf If you do not have access to a physician or nurse practitioner or if your child requires an individualized health care plan, contact your local Health Department. CC Revised 12/11 - All previous editions are obsolete and replaces OCC 1215A, and OCC Page 1 of 4 9

11 PART I - HEALTH ASSESSMENT To be completed by parent or guardian Child s Name: Birth date: Sex Address: Last First Middle Mo / Day / Yr M F Number Street Apt# City State Zip Parent/Guardian Name(s) Relationship Phone Number(s) W: C: H: Where do you usually take your child for routine medical care? Name: Address: When was the last time your child had a physical exam? Month: Where do you usually take your child for dental care? Name: W: C: H: Year: Phone Number: Address: Phone Number: ASSESSMENT OF CHILD S HEALTH - To the best of your knowledge has your child had any problem with the following? Check Yes or No and provide a comment for any YES answer. Yes No Comments (required for any Yes answer) Allergies (Food, Insects, Drugs, Latex, etc.) Allergies (Seasonal) Asthma or Breathing Behavioral or Emotional Birth Defect(s) Bladder Bleeding Bowels Cerebral Palsy Coughing Developmental Delay Diabetes Ears or Deafness Eyes or Vision Head Injury Heart Hospitalization (When, Where) Lead Poisoning/Exposure Life Threatening Allergic Reactions Limits on Physical Activity Meningitis Prematurity Seizures Sickle Cell Disease Speech/Language Surgery Other Does your child take medication (prescription or non-prescription) at any time? No Yes, name(s) of medication(s): Does your child receive any special treatments? (nebulizer, epi-pen, etc.) No Yes, type of treatment: Does your child require any special procedures? (catheterization, G-Tube, etc.) No Yes, what procedure(s): I GIVE MY PERMISSION FOR THE HEALTH PRACTITIONER TO COMPLETE PART II OF THIS FORM. I UNDERSTAND IT IS FOR CONFIDENTIAL USE IN MEETING MY CHILD S HEALTH NEEDS IN CHILD CARE. I ATTEST THAT INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. Signature of Parent/Guardian Date OCC Revised 12/11 - All previous editions are obsolete. Page 2 of 4 10

12 PART II - CHILD HEALTH ASSESSMENT To be completed ONLY by Physician/Nurse Practitioner Child s Name: Birth Date: Sex Last First Middle Month / Day / Year M F 1. Does the child named above have a diagnosed medical condition? No Yes, describe: 2. Does the child have a health condition which may require EMERGENCY ACTION while he/she is in child care? (e.g., seizure, allergy, asthma, bleeding problem, diabetes, heart problem, or other problem) If yes, please DESCRIBE and describe emergency action(s) on the emergency card. No Yes, describe: 3. PE Findings Health Area WNL ABNL Attention Deficit/Hyperactivity Behavior/Adjustment Bowel/Bladder Cardiac/murmur Dental Development Endocrine ENT GI GU Hearing Immunodeficiency REMARKS: (Please explain any abnormal findings.) Not Evaluated Health Area WNL ABNL Lead Exposure/Elevated Lead Mobility Musculoskeletal/orthopedic Neurological Nutrition Physical Illness/Impairment Psychosocial Respiratory Skin Speech/Language Vision Other: Not Evaluated 4. RECORD OF IMMUNIZATIONS DHMH 896/or other official immunization document (e.g. military immunization record of immunizations) is required to be completed by a health care provider or a computer generated immunization record must be provided. (This form may be obtained from: RELIGIOUS OBJECTION: I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any immunizations being given to my child. This exemption does not apply during an emergency or epidemic of disease. Parent/Guardian Signature: 5. Is the child on medication? (Child s Name) has had a complete physical examination and any concerns have been noted above. Additional Comments: Date: No Yes, indicate medication and diagnosis: (OCC 1216 Medication Authorization Form must be completed to administer medication in child care). 6. Should there be any restriction of physical activity in child care? No Yes, specify nature and duration of restriction: 7. Test/Measurement Results Date Taken Tuberculin Test Blood Pressure Height Weight BMI %tile Lead Test Indicated: Yes No Physician/Nurse Practitioner (Type or Print): Phone Number: Physician/Nurse Practitioner Signature: Date: OCC Revised 12/11 - All previous editions are obsolete. Page 3 of 4 11

13 CHILDREN WHO ARE REQUIRED TO RECEIVE LEAD TESTING Under Maryland law, children who reside, or have ever resided, in any of the at-risk zip codes listed below must receive a blood lead test at 12 months and 24 months of age. Two tests are required if the 1st test was done prior to 24 months of age. If a child is enrolled in child care during the period between the 1st and 2nd tests, his/her parents are required to provide evidence from their health care provider that the child received a second test after the 24 month well child visit. If the 1st test is done after 24 months of age, one test is required. The child's health care provider should record the test dates on page 3 of this form and certify them by signing and stamping the signature section of the form. All forms should be kept on file at the facility with the child's health records. AT RISK AREAS BY ZIP CODE Allegany ALL Anne Arundel Baltimore Baltimore (cont) Baltimore City ALL Calvert Caroline ALL Carroll Cecil Charles Dorchester ALL Frederick Garrett ALL Harford Howard Kent Montgomery Prince George s Prince George s (cont) Queen Anne's Somerset ALL St. Mary's Talbot Washington ALL Wicomico ALL Worcester ALL OCC Revised 12/11 - All previous editions are obsolete. Page 4 of 4 12

14 Publicity/Photography/Video Recording From time to time our program may involve photographing, video recording, interviewing by an outside source, and other publicity pictures of the children in our program. It is required by our licensing agent, Maryland State Department of Education and Maryland Department of Health and Mental Hygiene, that parents/guardians grant permission for this type of publicity. Please complete the portion below and it return to your Site Director. Please circle your choice: My child/ren may be photographed, video recorded, or interviewed for: (please check your choices) Yes No Yearbook page ABC Care Internet Site Newspaper/Magazine In-house speakers/field trips Scrap books for center Parent/Guardian Signature Date 14

15 TRANSPORTATION PERMISSION SLIP I,, give ABC Care, Inc. permission to transport my child/ren by certified school bus service and/or ABC Care, Inc. van to and from all field trips, and between all ABC Care, Inc. before and after school centers.. In case of emergency such as a natural disaster or national emergency, your signature on this blanket permission slip allows your child/ren to be transported by a Maryland certified bus company or ABC Care, Inc. staffer vehicle to the nearest disaster relief shelter. ABC Care, Inc. will notify parents/guardians of children s emergency location via telephone call. The emergency telephone number (s) we use to contact parents/guardians are listed on the child s emergency form. I understand that all necessary precautions will be taken by ABC Care, Inc. for the safety of my child/ren Parent Signature Date List child/ren s name(s) Please return to the Site Director or mail to the following address: ABC Care, Inc Patapsco Road Finksburg, MD

16 Behavioral Management Plan Minor behavioral problems will be handled by the center s Site Director through verbal warnings, cool down time, Problem Solving Sheets and Incident Reports. Both the Problem Solving Sheets and Incident Reports must be reviewed with the parent and the parent is required to sign the incident report. Parent Conferences Three (3) Incident Reports within a two (2) week period constitutes a parent conference to be held within one (1) week of the last Incident Report. These parent conferences will be held between the hours of 7:45am and 4:45pm and will be held either at the child s ABC Center or at the main office located at 2815 Patapsco Road, Finksburg, MD. Procedures Regarding Inappropriate Behavior A child who is involved in any type of behavior that is determined by the Site Director, and Executive Director or Senior Managers of ABC Care, Inc. to be conduct unacceptable for a child attending an ABC Care Before and After School Program, can be suspended or expelled. The Executive Director or Senior Managers have the authority to determine the length of the suspension, which can range from one (1) to five (5) days. ABC Care Inc. reserves the right to employ the following procedures in dealing with instances of inappropriate behavior: 1. The Site Director of the center may confiscate inappropriate and/or objectionable materials and/or objects that may be used for inappropriate behavior. 2. The Site Director of the center, with the Senior Manager s guidance, reserves the right to determine the degree of punishment (i.e. Incident Reports, suspension, expulsion) 3. The Executive Director or Senior Managers have the right to request full payment for total replacement and/or monetary reimbursement for repairs and/or replacement of broken/destroyed objects resulting from a deliberate or accidental breakage. This includes center equipment, school items, and children/staff personal belongings. 4. Field trips are a privilege. The Site Director of the center reserves the right to withhold a child from attending a field trip. 5. The Site Director of the center reserves the right to request that a child s parent accompany him/her while attending a field trip. 6. The Executive Director or Senior Managers reserve the right to require counseling and/or psychological testing. 15

17 Offenses The following lists are examples of SOME of the offenses for which a child may receive an Incident Report, suspension, or expulsion, depending on the circumstances and severity surrounding the offense. Incident Reports Leaving the designated area that ABC Care is utilizing at that time. Throwing rocks, snowballs.. Failure to refrain from hurting another (pinching, pushing, punching, biting, kicking, etc...) Using vulgar language, verbally or in written form Showing disrespect to another person (child or staff member) Improper use of equipment, materials, or furniture Suspensions which may result in expulsion Failure of parent(s) to attend a parent conference or adhere to its recommendations Theft/Robbery Use or possession of tobacco or firearms Arson/lighting matches Assault and battery of a staff member Violent behavior which creates a substantial danger to persons or property Possession of a real or look-a-like weapon Destruction and vandalism of school or personal property Fire alarm misuse Harassment Insubordination (disobeying a directive from a Director or School Age Child Care Teacher) Gambling for money Lack of required immunizations or health inventories Sexual activity or indecent exposure I have read and understand the behavioral management plan of ABC Care, Inc. and the procedures regarding inappropriate behavior and will agree to their implementation. Parent s Signature Child s Signature Date Date 16

18 Referral Program Membership Referrals This summer and school year will be an exciting one at ABC Care. Why not enjoy it with your friends? If you know of a potential new family who has never attended an ABC Care summer camp or before and after school year, please submit their contact information using the form below. If the referral joins ABC Care Summer Camp or Before and After school year this year, you will receive a $50 credit towards tuition. Referred family need only to register and attend for at least 1 week for camp or 1 month for school year. You must be a current registered family with your account in good standing when the referred family joins. Upon full payment by your referral, the referring family will receive their credit. There will be no cash refund of the referral credit Referral Form Your Information Your Full Name: Your Phone Number: Child s Name Attending: Camp Your Child Attends: Date Submitted: Information for Individual/Family you are Referring: First Name: Last Name: Phone: This Phone # is their: Home Work Other Notice: Referral must be turned in at time of registration payment. 17

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