Hillside Community Preschool Child Enrollment Information Form

Transcription

1 For Office Use Enrollment : Hillside Community Preschool Child Enrollment Information Form Start : Registration Fee: Payment Type: Check Cash Child Information Check Number: Child s Last Name Child s First Name Child s Nickname (if used) Child s Birth date Gender Child s Home Language Child s Race/Ethnicity Child Lives With? Is there a court-ordered custody arrangement for this child? Yes No (If yes, please provide a copy.) Class Enrolled in: M-F (Born between Oct. 2, 2009-Oct. 1, 2011) Family Information Parent or Guardian 1 Relationship to Child Address (one per family or address) Home Address City State Zip Code Home Phone Work Phone Cell Phone Occupation Employer Employer Address City State Zip Code Parent or Guardian 2 Relationship to Child Address (if different from Parent 1) Home Address (if different from Parent 1) City State Zip Code Home Phone Work Phone Cell Phone Occupation Employer Employer Address City State Zip Code 1

2 Contact Information Local contact person (e.g. friend, neighbor or relative) if parent is unavailable: Please prioritize contacts in order of who should be called first. At least one must be listed as an Emergency contact. Name Relation to Child OK to Pickup? Yes No Emergency Contact? Yes No Phone Address City State Zip Code Name Relation to Child OK to Pickup? Yes No Emergency Contact? Yes No Phone Address City State Zip Code Name Relation to Child OK to Pickup? Yes No Emergency Contact? Yes No Phone Address City State Zip Code Medical Contact Information Child s Physician Practice Name Phone Physician s Address City State Zip Code Child s Dentist Practice Name Phone Dentist s Address City State Zip Code Hospital Phone Hospital Address City State Zip Code I agree to have my child examined by a physician annually and medical information returned to HCP for their files. Initial I give my permission to be listed in the HCP Directory: Initial 2

3 I give my permission to receive s concerning late starts, weather closures, reminders, newsletter, special events, and updates. Parent/Guardian #1intial Parent/Guardian #2 initial I agree to comply with the program rules which are established and periodically amended by board members of Diakonia. I give permission to have my child receive emergency medical treatment as deemed necessary by the personnel at Hillside Community Preschool. I understand that while constant supervision of my child is provided by the staff of HCP, there is inherent risk of injury to my child from activities in the classroom, on the playground and in the building facilities of HCP. I accept this risk and on behalf of me and my spouse, if applicable, my child, and his/her and our heirs and legal representative, waive and release HCP from any and all claims (excluding only willful misconduct) for injuries sustained by my child while in the HCP program, and waive and release any claim for consequential and exemplary damages. I agree to indemnify and hold harmless and its agents and employees from any claim brought by or on behalf of my child, which is inconsistent with the above waiver and release. Parent or Guardian Signature Specific Health Concerns Child s Name of Birth Allergies: Yes No Restrictions: Yes No if yes, please specify. if yes, please specify. Operations/Serious Illnesses: Yes No if yes, please specify. List any behavior or other special considerations: Health Insurance Coverage Information Health Insurance? Yes No Address: Insurance Company Phone Number Policy Number 3

4 Group Number If this information changes during the school year, I agree to inform Hillside Community Preschool of the changes. Parent/Guardian Signature If you do not wish to provide full health insurance information, please initial here. Authorization for Access to Child Health Information I, the parent/guardian of authorize the staff of Hillside Community Preschool to have access to my child s health information as provided to HCP (General Health Appraisal form, Immunization records, Health Insurance Coverage Information, specific health care plans). I understand that the records will be reviewed for completeness by office staff and HCP nurse consultant, and may be accessed other times through the school year by Colorado s State Licensing Representative on an individual, as needed basis. I also authorize contact with my child s physician via phone, fax or in writing as needed to continue medical care. Records are considered confidential material. Parent/Guardian Signature 4

5 Hillside Community Preschool Emergency Medical Consent Name: Birth : Sex: M F Address: Mother s Name: Tel(h) Tel(w) Tel(c) Father s Name: Tel(h) Tel(w) Tel(c) Emergency Contact Name: Hospital: Doctor: Dentist: Most Recent Tetanus Shot: Tel Tel Tel Tel MMR Allergies/Medications/Disabilities: Health Insurance Company: Health Insurance Card Number: HIB Vaccine: Enrolment in Program: It is our policy to notify a parent when a child is ill or needs medical attention. Occasionally we cannot contact parents and we need to get immediate help for the child. Please sign the consent below so that we can take appropriate action on behalf of your child. We will take this signed consent with us to the emergency center. I authorize the staff or person(s) in charge of HILLSIDE COMMUNITY PRESCHOOL, to call a physician, or summon an ambulance for emergency medical aid; should, in the opinion of the person(s) in attendance, feel such services are required and I cannot be contacted by phone. If such emergency should arise, I shall be notified as soon as possible. I agree that any cost incurred for such services shall be the sole responsibility of myself. Parent Signature: : 5

6 HILLSIDE COMMUNITY PRESCHOOL Volunteer Opportunities School Year Child s Name Child s Class Class Days address Phone Number Best way to reach you ( ) Help Organize Teacher Appreciation Week ( ) Help with Scholastic Book Orders ( ) Room Parent ( ) Organize meals for monthly staff meetings ( ) Special Visitor Willing to Share a Talent or Share the Tools of their Occupation (e.g., construction, truck driver, hair stylist, dental hygienist, police officer, fire fighter, chef, new baby, etc.) (If you would like to be one of our special classroom visitors, please indicate what you would like to share on the line below and we will touch base to set up a time.) I would like to visit the class and share: Thank you for volunteering to make HCP a wonderful place for families!! Hillside Community Preschool Sunscreen Permission Form 6

7 Dear Parents, This form gives your child s teacher permission to put sunscreen on your child. The teacher will be provided with sunscreen to put on your child. If your child has any skin allergies to sunscreen please let the director and your child s teacher know and provide your child s sunscreen. Child s Name Class Teachers Names I Do give my child s teachers permission to put sunscreen on my child: Yes No I Do not give my child s teachers permission to put sunscreen on my child: Yes No_ I will provide my child with his/her own sunscreen to be applied by my child s teachers (Please label child s name on the sunscreen) Parent/Guardian Sgnature Parent Release Form for Shutterfly I, the undersigned, do hereby grant/deny permission to Hillside Community PRESCHOOL to use the image of my child,, through photographs, images, and/or video taken of my child for the class Shutterfly website. Deny permission to use my child s image at all. Grant permission to use my child s image in the Shutterfly class website Parent/Guardians Signature Permission for Classroom Photos 7

8 I give permission for my child, to be photographed by Hillside Community Preschool staff for classroom purposes. These photos may be displayed in the Hillside Community Preschool classroom area, information board, and classroom projects. I understand that no photos of my child will be published or distributed in any way. Parents/Guardian signature I do not grant permission for my child to be photographed by Hillside Community Preschool staff for classroom purposes. My child s photo may not be displayed in the Hillside Community Preschool classroom area, information board, or in classroom projects. Parent s/guardian signature Permission to Participate in Walking Field Trips I give my permission for my child, to participate in Walking Field Trips in the local area near Hillside Community Preschool accompanied by the classroom teachers. Parents/Guardian signature I do NOT give my permission for my child to participate in Walking Field Trips in the local area near Hillside Community Preschool accompanied by the classroom teachers. Parents/Guardian signature 8

9 PARENT please complete AND SIGN GENERAL HEALTH APPRAISAL FORM Child s Name: Birthdate: Allergies: q None or Describe Type of Reaction Diet: q Breast Fed q Formula qage Appropriate qspecial Diet Sleep: Your health care provider recommends that all infants less than 1 year of age be placed on their back for sleep. q Preventive creams/ointments/sunscreen may be applied as requested in writing by parent unless skin is broken or bleeding. I, give consent for my child s care health provider, school child care or camp personnel to discuss my child s health concerns. My child s health provider may fax this form (& applicable attachments) to my child s school, child care or camp personnel. FAX #: DATE: Parent/Guardian Signature HEALTH CARE PROVIDER: Please Complete After Parent Section Completed of Last Health Appraisal: Exam: Physical Exam: q Normal q Abnormal (Specify any physical abnormalities) Allergies: q None or Describe Type of Reaction Significant Health Concerns: qsevere Allergies qreactive Airway Disease qasthma qseizures qdiabetes qhospitalizations qdevelopmental Delays qbehavior Concerns qvision qhearing qdental qnutrition q Other Explain above concern (if necessary, include instructions to care providers): Current Medications/Special Diet: q None or Describe Separate medication authorization form is required for medications given in school, child care or camp For Fever Reducer or Pain Reliever (for 3 consecutive days without additional medical authorization) PLEASE CHOOSE ONE PRODUCT qacetaminophen (Tylenol) may be given for pain or fever over 102 degrees every 4 hours as needed Dose or see the attached age-appropriate dosage schedule from our office OR qibuprofen (Motrin, Advil) may be given for pain or for fever over 102 degrees every 6 hours as needed Dose or see the attached age-appropriate dosage schedule from our office Immunizations: qup-to- q See attached immunization record qadministered today: Health Care Provider: Complete if Appropriate **ONLY REQUIRED BY EARLY HEAD START AND HEAD START PROGRAMS PER STATE EPSDT SCHEDULE** ** Exam ** B/P **Head Circumference (up to 12 months) ** ** HCT/HGB ** Lead Level qnot at risk or Level **TB qnot at risk or Test Results q Normal q Abnormal **Screenings Performed: qvision: qnormal qabnormal qhearing: qnormal qabnormal qdental: qnormal qabnormal- Recommended Follow-up Provider Signature Next Well Visit: q Per AAP guidelines* or q Age This child is healthy and may participate in all routine activities in school sports, child care or camp program. Any concerns or exceptions are identified on this form. Office Stamp Or write Name, Address, Phone, # Signature of Health Care Provider (certifying form was reviewed) : The Colorado Chapter of the American Academy of Pediatrics (AAP) and Healthy Child Care Colorado have approved this form. 04/07 *The AAP recommends that children from 0-12 years have health appraisal visits at: 2, 4, 6, 9, 12, 15, 18 and 24 months, and age 3, 4, 5, 6, 8, 10 and 12 years. Copyright 2007 Colorado Chapter of the American Academy of Pediatrics

10 COLORADO LAW REQUIRES THAT THIS FORM BE COMPLETED FOR EACH STUDENT ATTENDING COLORADO SCHOOLS Name of Birth Parent/Guardian COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT CERTIFICATE OF IMMUNIZATION Vaccine Enter the month, day and year each immunization was given Hep B Hepatitis B DTaP Diphtheria, Tetanus, Pertussis (pediatric) DT Diphtheria, Tetanus (pediatric) Tdap Tetanus, Diphtheria, Pertussis Td Tetanus, Diphtheria Hib Haemophilus influenzae type b IPV/OPV Polio PCV Pneumococcal Conjugate MMR Measles, Mumps, Rubella Measles Measles Mumps Mumps Rubella Rubella Varicella Chickenpox Healthcare Provider Documentation Lab Verification Vaccines recorded below this line are recommended. Recording of dates is encouraged. HPV Rota MCV4/MPSV4 Hep A TIV/LAIV Human Papillomavirus Rotavirus Meningococcal Hepatitis A Influenza Other THIS SECTION CAN BE COMPLETED BY CHILD CARE/SCHOOL/HEALTH CARE PROVIDER A) Child Care Up to Up to date through 6 months of age for Colorado School Immunization Requirements Update Signature B) Child Care Up to Up to date through 18 months of age for Colorado School Immunization Requirements Update Signature C) Child Care/Pre-school/Pre-K* Up to date for Child Care/Pre-School/Pre-K for Colorado School Immunization Requirements Update Signature D) Complete for K 5th Grade Up to date for K 5th Grade for Colorado School Immunization Requirements Update Signature * If age 4 years and fulfills Requirements for Pre-School & Kindergarten, check BOTH Boxes C and D. HAS MET ALL IMMUNIZATION REQUIREMENTS FOR COLORADO SCHOOLS (6TH GRADE OR HIGHER) Signed Title (Physician, nurse, or school health authority) CDPHE-IMM CI RC Rev. 5/13

11 Name of Birth Parent/Guardian STATEMENT OF EXEMPTION TO IMMUNIZATION LAW (DECLARACIÓN RESPECTO A LAS EXENCIONES DE LA LEY DE VACUNACIÓN) IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS MAY BE SUBJECT TO EXCLUSION FROM SCHOOL AND TO QUARANTINE. SI SE PRESENTA UN BROTE DE LA ENFERMEDAD, ES POSIBLE QUE A LAS PERSONAS EXENTAS SE LES PONGA EN CUARENTENA O SE LES EXCLUYA DE LA ESCUELA. MEDICAL EXEMPTION: The physical condition of the above named person is such that immunization would endanger life or health or is medically contraindicated due to other medical conditions. EXENCIÓN POR RAZONES MÉDICAS: El estado de salud de la persona arriba citada es tal que la vacunación significa un riesgo para su salud o incluso su vida; o bien, las vacunas están contraindicadas debido a otros problemas de salud. Medical exemption to the following vaccine(s): La exención por razones médicas aplica a la(s) siguiente(s) vacuna(s): Hep B DTaP Tdap Hib IPV PCV MMR VAR Signed (Firma) Physician (Médico) (Fecha) RELIGIOUS EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a religious belief opposed to immunizations. EXENCIÓN POR MOTIVOS RELIGIOSOS: El padre o tutor de la persona arriba citada, o la persona misma, pertenece a una religión que se opone a la inmunización. Religious exemption to the following vaccine(s): Exención por motivos religiosos de la(s) siguiente(s) vacuna(s): Hep B DTaP Tdap Hib IPV PCV MMR VAR Signed (Firma) Parent, guardian, emancipated student/consenting minor (Padre, tutor, estudiante emancipado o consentimiento del menor) (Fecha) PERSONAL EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a personal belief opposed to immunizations. EXENCIÓN POR CREENCIAS PERSONALES: Las creencias personales del padre o tutor de la persona arriba citada, o la persona misma, se oponen a la inmunización. Personal exemption to the following vaccine(s): Exención por creencias personales de la(s) siguiente(s) vacuna(s): Hep B DTaP Tdap Hib IPV PCV MMR VAR Signed (Firma) Parent, guardian, emancipated student/consenting minor (Padre, tutor, estudiante emancipado o consentimiento del menor) (Fecha)