Before and After School Program

Mount Hope Academy 6823 Harrison Road Fredericksburg, VA 22407 Phone (540) 785-4631 Fax (540) 548-2540

Before & After School Program Registration Form

Serving the following schools:

Battlefield Elementary Courthouse Road Elementary Courtland Elementary Harrison Road Elementary Parkside Elementary Salem Elementary Smith Station Elementary Wilderness Elementary Faith Baptist Battlefield Middle Chancellor Middle Ni River Middle Freedom Middle

Hours of Operation: 5:30 A.M- 6:30 P.M.

Breakfast & Evening Snack Served

Revised February 2017 Before and After School Program Registration / Enrollment Form Date______

Child’s Name ______Birth date______Nickname______Sex______

School Attending ______Grade Level______

Check Program Schedule that applies

_____ Morning & Afternoon Care (Check) ___M___T___W___Th___F _____ MorningCare (Check) ___M___T___W___Th___F _____ Afternoon Care (Check) ___M___T___W___Th___F ______Occasional Care

Parents

Mother’s Name______Address______Street City Zip Home Phone ( ) ______Cell Phone ( ) ______Email ______Place of Employment ______Work Phone ( ) ______Business Address______Street City Zip

Father’s Name______Address ______Street City Zip Home Phone ( ) ______Cell Phone ( ) ______Email ______

Place of Employment______Work Phone ( ) ______Business Address______Street City Zip Emergency Information

Child’s Physician______Phone ( ) ______Address______Street City Zip

Person(s) to contact if parents cannot be reached in case of an emergency:

Name Address Relationship Phone Number Person(s) Authorized To Pick Up Child

Name Address Relationship Phone Number

Person(s) Not Authorized To Pick Up Child

Name Address Relationship Phone Number

3 Mount Hope Academy 6823 Harrison Road Fredericksburg, VA 22407 Phone: 540-785-4631/Fax: 540-548-2540

Date: ______

To: ______(School Name)

Attn:______(Principal or Administrator)

From: ______(Parent Name)

Please be advised that my child______has permission to ride: (child’s name)

MHA Vans ______

School Bus # ______from Mount Hope Academy to ______in the mornings (school name) and will return by the same means of transportation to Mount Hope Academy at the end of each school day.

Parent signature:______

4 Mount Hope Academy Before & After School Program

Health Form/Physical Assessment

Child’s Full Name Birth date

1. Allergies (food, medication, insects, etc……______

2. Chronic or recurrent illnesses or disorders: ______

3. Significant surgeries or special related health ______care needs ______

4. What should Program staff do if you child has a problem related to his/her medical condition during program hours? ______

5. How does your child get along with other children? ______

Please provide a copy of your child’s immunization record.

Please be aware that we will administer prescription and non-prescription medications. Medications will be administered by a MAT trained staff member at 11:00 a.m. and 3:00 p.m. Please adjust your child’s medication schedule accordingly. A parent/guardian/custodian may come to the Academy at any time to administer his/her child’s medication.

5 ALLERGY RELEASE FORM

I HEREBY NOTIFY THE STAFF OF Mount Hope Academy’s Before and After School Program that my child ______is allergic to the following Child’s Name substances/foods, and could suffer a negative reaction if exposed to these substances/foods. Attached is a Physician’s Verification of this allergy.

______

I understand that the staff will to the best of their ability monitor any substances/foods my child eats or is exposed to, and I hereby release Mount Hope Academy and its staff from any liability which may result from my child’s accidental exposure to such substances/foods.

I authorize Mount Hope Academy’s MAT certified staff members to administer the following medications to my child on an emergency basis to alleviate reactions to the above substances/foods: ______

______

I understand that it is my responsibility to assist in the training of emergency care required by my child and that the staff will to the best of their ability follow the procedures. I release Mount Hope Academy and its staff from any liability, which may result from the administration of the above medication.

______Parent or Guardian Signature Date

Notarized seal: ______

6 CONSENT FOR EMERGENCY TREATMENT

I give my consent to the personnel of Mount Hope Academy to give emergency treatment to my child in the event of illness or injury, while he/she is at Mount Hope Academy.

I understand that only emergency treatment will be given and that I am responsible for follow-up treatment if needed.

Child’s Name: ______Age: ______

SIGNIFICANT MEDICAL HISTORY:

Allergies: ______

Unusual Drug Response: ______

Medication: ______

Epilepsy: ______

Rheumatic Fever: ______

Heart Disease: ______

Other (Asthma or other medical conditions): ______

______Parent or Guardian Signature Date ______Work Phone Number ______Home Phone Number

Notarized seal: ______

7 CHILD’S EMERGENCY MEDICAL AUTHORIZATION

Completion of this form is voluntary however; the penalty for not completing it may be a delay of processing or denial of admission. This information is gathered to promote the health and safety of all children enrolled.

Child’s Name: ______DOB: ______

Name of Parent(s) or Guardian______

Home Address: ______Street City zip code

Mother’s Employment: ______Company Name Company Phone Number

Company Address: ______

Father’s Employment: ______Company Name Company Phone Number

Company Address: ______

Mother’s Cell#______Father’s Cell#______

The Parent(s)/guardian authorizes ______Name of School to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to, his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that this agreement covers only those situation which are true emergencies and only when he/she cannot be reached. Otherwise, he/she expects to be notified immediately.

1. I/we will be responsible for payment of medical care expenses. ______

2. Medical treatment costs are covered by: a. Private Insurance ______(name of company & policy no.)

b. Medicaid Coverage No. ______

c. Other medical insurance: ______(name of company & policy no.)

8 d. No insurance ______

Child’s Physician name or clinic attended ______

______Signature (Parent(s)/Guardian) Date

I also acknowledge as my responsibility and consent to make available to my child when and if necessary, later: a. A complete physical examination, including urinalysis, hematocrit, and follow-up care. b. A TB skin test c. Childhood shots, pertussis, tetanus (DPT), smallpox, polio vaccine, and measles vaccine. d. Psychological evaluation and treatment. e. Vision, hearing and dental services

Signature: ______Date: ______

Notarized seal: ______

9 Mount Hope Academy’s Decision to Administer Medications Plan

Mount Hope Academy has made the following decision regarding the administration of medications to a child in our program:

We WILL administer prescription and non-prescription medications. Medications will be administered by a staff member who has taken MAT (Medication Administration Training) at 11:00 a.m. and 3:00 p.m. Please adjust your child’s medication schedule accordingly. We will not be able to administer medication at any other time. A parent/guardian/custodian may come to the Academy at any time to administer his/her child’s medications.

If your child is on any medication, which needs to be administered while he/she is at school, he/she must have on file in the office the authorization for administration form. This form must be updated every six months for long-term medication and every ten days for short-term medication. This form is available in the Academy office and online at www.mhacademy.org. It must have the physician’s signature (if administered more than 10 days). The medication to be administered will be kept in a locked cabinet in the Academy office. The medicine must be in the original container. Over-the-Counter medication should be labeled with the child’s first and last names. Prescription Medication should be in a child resistant container. It must have the original pharmacy label that includes the following items: (1) Child’s first and last name, (2) Doctor’s Name, (3) Pharmacy name and telephone number, (4) Date Prescription was filled, (5) Name of Medication, (6) Dosage of the medication, (7) Route of administration, (8) How often to give the medication, (9) Date the medication is to be discontinued or length of time, in days, the medication is to be given. Parents must provide administration tools, such as dosing spoons, oral medication syringes, pill crushers, etc. STUDENTS MAY NOT TRANSPORT MEDICATION TO AND FROM SCHOOL.

Authorized Staff to Administer Prescription Medications

MHA will administer prescription medication in accordance with the physician’s or other prescriber’s instructions and in accordance with the MAT standards of practice. Only a provider who has successfully completed MAT or has appropriate licensure to administer prescription medications and is listed as a medication administrator in this plan will be permitted to administer prescription medications at MHA.

We understand that any individual listed in this section as a medication administrator is approved to administer prescription medications using the following routes: topical, oral, inhaled, eye, and ear, medication patches and epinephrine using an auto-injector device.

We understand that if a child enrolled in MHA requires prescription medication to be administered rectally, vaginally, by injection or by another route not listed above, we will follow the procedures outlined in MAT for children with special health care needs.

We understand that to be approved to administer prescription medication, all individuals listed in this plan (unless the individual is licensed to administer prescription medications) must have a valid:

 Medication Administration Training (MAT) certificate;

10  CPR certificate which covers all ages of the children MHA is approved to care for as listed on our registration; and  First aid certificate which covers all ages of the children MHA is approved to care for as listed on our registration.

Medication Administrators

MAT certificates (or documentation of licensure to administer prescription medication), age-appropriate first aid certificates, and CPR certificates for the staff listed below will be kept on site and be available upon request.

Corliss Shepherd Ruby Houston Sophia Byrd Emyli Shepherd Tisha Thrash Sharita Minor

Confidentiality Statement

Information about any child at MHA is confidential and will not be given to anyone except VDSS’ designees or other persons authorized by law unless the child’s parent or guardian gives written permission. Information about a child enrolled in MHA will be given to the local department of social services if the child receives a day care subsidy or if the child has been named in a report of suspected child abuse or maltreatment or as otherwise allowed by law.

Rehabilitation Act of 1973

We understand that if MHA receives any federal funding (such as child care subsidy from a local department of social services), We are subject to Section 504 of the Rehabilitation Act of 1973 which is similar to the provisions of the Americans with Disabilities Act. If a child enrolled in MHA now or in the future is identified as having a disability covered under the Rehabilitation Act, We will assess the ability of MHA to meet the needs of the child (for further information on the Rehabilitation Act seek legal counsel and/or go the following website: http://www.dol.gov/oasam/regs/statutes/sec504.htm

Provider Statement

We understand that it is our responsibility to follow MHA’s Decision to Administer Medication Plan and all health and infection control regulations applicable to our program. We will verify and document the credentials for all new staff certified to administer prescription medications before the staff is allowed to administer prescription medications to any child at MHA. MHA’s Decision to Administer Medication plan will be made available to parents at enrollment, whenever changes are made and upon request.

Facility Name: Mount Hope Academy Date: February 24 , 2017

Parent’s Signature: Date:

11 PERMISSION TO PUBLISH STUDENT INFORMATION

Mount Hope Academy publishes a variety of information about our school and its activities to the public through various media, including print, our website, and social media. We may wish to include your child’s name and/or photograph. This information might be used to recognize achievement, or promote the Academy, in brochures, newsletters, magazines, newspapers, or on the Internet. Your signature below acknowledges permission for this information to be published.

My child’s name may be published.

YES_____ NO_____

Photographs of my child accompanied by his/her name, may be published.

YES_____ NO_____

Photographs of my child without his/her name, may be published.

YES_____NO_____

My child’s work may be published.

YES_____ NO_____

I hereby give the above permissions and release Mount Hope Academy and Mount Hope Baptist Church from liability resulting from or connected with the publication of this information.

______(Child’s) First Name, MI, Last Name

______Parent or Guardian Signature

Date: ____/____/____

12 EMERGENCY EVACUATION PERMISSION SLIP

In the event of an emergency evacuation, Mount Hope Academy has my permission to transport my child/ren ______using the Academy (Child’s Name) vans, staff vehicles, and/or parent vehicles to the following facilities:

Creative Childcare Academy 7001 Harrison Road Fredericksburg, VA 22407 (540) 548-8003

Salem Fields Early Learning Center 11120 Gordon Road Fredericksburg, VA 22407 (540) 786-6292

Minnieland at the Castle 6306 Old Plank Road, Fredericksburg, VA 22407 (540) 786-2434

______You have my permission to transport my child.

______You do not have my permission to transport my child.

______Please Print Signature Date

Mount Hope Academy

Summary of Fees for Before and After Care Program

Registration Fee: (Non –Refundable) $20.00

Before and After Care $75.00 weekly (Hours of operation: 5:30am-8:00am and 3:00pm-6:30pm)

Before Care $60.00 weekly (Hours of operation: 5:30am-8:00am)

After Care $60.00 weekly (Hours of operation: 3:30pm-6:30pm)

Extended Care $30.00 Daily (Note: Extended care pertains to, our providing service from 8:00-3:30pm, when school is closed. I.e.: Teacher Workday, Holidays, Winter break, Spring break, etc….). This service is offered to students who regularly attend before and/or after care

Occasional Full Day $40.00 Daily Occasional Before Care or After Care $15.00 Daily Occasional Before and After Care $25.00 Daily

Late Pick-up fee of $2.00 per minute, per child for pickup after 6:30 p.m. To avoid this fee, please contact someone on my emergency list to pick up my child/children.

Late Payment Fee $30.00

14 Returned Check Fee $35.00 Before & After School Program Enrollment Agreement

I. I understand that I am enrolling my child: ______for the current school year. He / she will attend: _____ Mornings & Afternoons (Please Check) ___M___T___W___Th___F _____ Mornings (Please Check) ___M___T___W___Th___F _____ Afternoons (Please Check) ___M___T___W___Th___F _____ Occasional Mornings and/or Afternoons _____ Occasional Full Day II. I understand the Program is open according to the official school calendar of the Spotsylvania County School District with the exception of the following: the program will be closed on March 30, 2018 and June 15, 2018, and is closed during vacations, Holidays, and inclement weather days. III. I understand that weekly tuition payments are due in advance by close of business on Friday. Payments received after this time will be assessed a $30.00 late fee. Delinquent accounts must be paid- in-full by close of business the following day. Your child/ren will not be permitted to attend the program until payments are made in full. IV. I understand that I must pay tuition as scheduled even when the public schools are closed for winter break, spring break, etc. V. I will give 2 weeks notice in writing prior to withdrawal from the program during which time I will be responsible for payment of fees. VI. I understand that in the event of any absences during program hours, activities, I will be responsible for all applicable fees. VII. I understand that when occasional care is needed I must call ahead for approval before dropping my child off, occasional care is contingent on staff and space available, and payment is due when I drop my child off. VIII. I will update my child’s parent contact information as needed to keep the program staff informed of any changes. I understand that this is necessary for the program staff to be able to reach me while my child is in attendance. IX. I understand that the program staff will assume full responsibility for my child from the time he/she arrives at the program until my child leaves the program according to the written instructions for departure. X. The program staff agrees to notify the parent/guardian/custodian whenever the child becomes ill and the parent agrees to pick the child within an hour after being notified. XI. I agree to notify the Academy whenever my child will not be in attendance and/or whenever my child will not need transportation from school. XII. I agree to provide a suitable booster seat for my child if he/she is under the age of eight years to be used when my child is supported to and from their school. XIII. The parent/guardian/custodian authorizes the Academy to obtain immediate care if any emergency occurs when he/she cannot be located. XIV. If a medical emergency arises, the program staff will first attempt to contact the parent. If the parent cannot be reached, the staff will contact the child’s doctor. If the emergency is such that immediate hospital attention is necessary, an ambulance or emergency vehicle may take the child to the hospital.

I agree to adhere to the stated policies and procedures of the Before and After School Program as stated here and in the Parent Handbook, and give my child permission to participate fully in this program.

Date Parent/Guardian/Custodian 15 ______Date Parent/Guardian/Custodian

FOR OFFICE USE ONLY

Child’s Name: ______

Parent’s Name: ______

Confirmation of receipt of required forms: Enrollment Agreement: _____ Child Health Record: _____ Pick-Up Authorization & Consent for Emergency Treatment / Medical Consent: _____

Initial Tuition Rate: $ _____ / per week Sibling Discount: _____% $ _____ / week Child’s beginning date of attendance: ______Child’s enrollment termination date: ______Advance Deposit Received: Yes / No Date Received: ______

Amount Received: ______

Receipt #: ______