Harmony Early Childhood Education Center Registration Form

Transcription

1 Harmony Early Childhood Education Center Registration Form Today s date: Starting date: Case #: Child s Name: Classroom: (First Name) (Last Name) Date of birth: Home Phone: Gender: Boy Girl Mom s Work Phone: Language(s) spoken: Mom s Cell Phone: Dad s Work Phone: Dad s Cell Phone: Mother s Name: Ethnicity: (Or Guardian s name) (First Name) (Last Name) Street address: City: State: Zip code: Father s Name: Ethnicity: (Or Guardian s name) (First Name) (Last Name) Street address: City: State: Zip code: For Staff Use Only: Arrival Time: Departure Time: Days: M. T. W. Th. F. Full day Payment Type: Registration Fee: $ Ck# Deposit: $ Ck# Monthly payment: $ DSHS monthly Co-Pay $ Parent Handbook: Parental Responsibilities / Acknowledgement: Security Code: Notes: 1

2 HEALTH SCREENING Child s Dentist: Phone Number: N/A Parent Initial Address: Primary Doctor: Phone Number: N/A Parent Initial Address: Date of Child s Last Physical examination date: Immunizations up to date: (Yes) (No) (Please ask staff if you need help) 1. Does your child presently have any health problems? (Yes) (No) If yes, please explain: 2. Does your child have any chronic health conditions: (Yes) (No) If yes, please explain: 3. Does your child have sleep disturbances-nightmares, sleep-walking, waking up at night or difficulty going to sleep? (Yes) (No) If yes, please explain: 4. Does your child have any special talent or hobbies that he/she enjoys? (Yes) (No) If yes, please explain: 5. Have you left your child in daycare or with a babysitter before? (Yes) (No) If yes, please explain: 6. Is your child toilet trained? (Yes) (No) 7. Is your child taking any medications? (Yes) (No) What? 8. Is your child allergic to any food or drink? (Yes) (No) Please circle below: --Milk Orange juice Apple juice Peanuts Other 9. Can your child have soy bean drink? (Yes) (No) 10. Does your child wear diapers? (Yes) (No) 11. Does your child have any allergies? (Yes) (No) What? Anything else you would like to share with us about your child: 2

3 Consent to Medical Care and Treatment of Minor Children I hereby give permission that my child,, may be give emergency treatment by a (Child s Name) qualified child care provider at Harmony Early Childhood Education Center, procedures to be performed for my child by a licensed physician, health care provider, hospital or aid care attendant when deemed necessary or advisable by the physician or aid car attendant to safeguard my child s health. I waive my right of informed Consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I,, under penalty of perjury under the laws of the State of Washington (name of parent or Guardian s name) that the foregoing is true and correct. (Parent or Guardian s Signature) (Date) Person to be contacted in an emergency pick up my child: Please have the designated person(s) bring a picture ID when he or she comes to pick up your child. Without the ID, we will not release your child. 1. Name: Phone: Relation to the child: 2. Name: Phone: Relation to the child: ( #3 need to be out of Washington State person for earthquake purpose, thank you!) 3. Name: Phone: Relation to the child: Classroom Activity I, do / do not wish my child to participate in enrichment activity of Music and Dance. I understand there is an additional cost of $35.00 or $25.00 per month if I chose to have my child participate. Permission to Photograph I give permission for my child to be photographed or videotaped in scheduled Harmony Early Childhood Education Center activities. Such photographs and videotape may be used by Harmony Early Childhood Education Center for publicity or educational purposes. YES NO Field Trips I give Harmony Early Childhood Education Center permission to take my child to visit the parks around downtown Renton and along the Cedar River Trails. YES NO Sun Block Lotion I give Harmony Early Childhood Education Center permission to provide Banana Boat Baby Tear Free SPF 50 sun block to my child during the summer. YES NO Parent or Guardian s Signature: Date: 3

4 First day of school Check List First of School: Password to Enter Harmony: Parents need to Provide: Item from Parents Parent s checking list 1. A pair of clean indoor shoes Please show your child where to put her belongings (cloth,cup,toothbrush and Shoes). 2. Complete change of clothes, please includes socks and underwear. Please put them all in one ZIP Plastic Bag and write your child s name on it. 3. Blanket Please bring home to wash every month of last Friday. Please write down your child s name. Sheet must be purchased from Harmony ECE $12.00 additional charge (one time) Clear Zip Bag (example) $ x6 child or family picture For cubby use. 5. Diapers or pull ups At least one week supply boxes of Kleenex (tissue paper with location, for classroom use only) 7. 2 Boxes of Wipes if wearing diapers or pull ups 2 Box of gloves if wearing diapers or pull ups We will ask parents regularly to bring the Kleenex; it will depend on how often children will use them. 1 box will be used for out door or classroom activity. We will ask parents regularly to bring the wipes and gloves; it will depend on how often the child uses it. 8. Purchase gloves at Harmony for your convenience. (100 gloves for $10.00) $10.00 (100 gloves each) will be charged to your next invoice if it is purchased from Harmony Box of wipe for Preschoolers We will ask parents regularly to bring the wipe and gloves; it will depend on how often 1 Box of Gloves children will use them. 10. Toothbrush, kids toothpaste and Cup (Caterpillar and Butterfly class only) Please write your child s name on each item. 11. We strongly encourage parents to label everything in permanent marker in order to identify lost items. 4

5 Harmony Conversation Log Child s Name: Date of Birth: Parent s Name: Tel: Today s day: Date Regarding of Registration was given on by. Spoke to DSHS: Case has approved from to units Co-Pay is $ Starting the Co-pay will be. The case has been denied. First day of School at Harmony is : 5