Step-By-Step

Step By Step EDU Play, Inc. Toddler & Preschool After School Enrichment Program/Kinder, Transitional K, Kinder , 1st After School Program Registration Registration Date:______Child's name: LAST FIRST Date of Birth MIDDLE

Parent(s) or Legal Guardian Name: Relationship Marital Legal Status Rights 1) 2)

Address: City: State: Zip:

PARENT or Legal CONTACT INFO: #1 CONTACT: #2 Guardian Home phone Cell Email  How were you referred to Step By Step? ______

Funding Information: ( ) Private Pay ( ) Other:______

( ) Regional Center Service Coordinator ______

Please indicate the start date/months that you are planning for your child to attend: ______(example: Sept. 2010-Dec. 2010)

www.StepByStepEDUPlay.com * 1814 14th Street * Santa Monica, CA 90404 Phone: 310-581-0590 * Fax: 310-581-0589 ______(Parent/Guardian) (Signature) (Date) * Please note that we need 24 hours notice if you plan to send your child on days that are unscheduled previously in order to staff appropriately for safety purposes.

Please check off the age group that applies to your child: Toddler Age _____ Preschool age _____ Elementary age _____

Please circle which days you would like to send your child:

Monday Tuesday Wednesday Thursday Friday

Before care option

Will you child be attending Before Care between 7:30-9:00am? If So, What time will your child’s bus be picking them up?______

Please check off the times you would like your child to stay for:

Toddler Enrichment Program (1-3 years old) 11:00-11:30 Arena – Free choice 11:35-12:05 204 – Lunch bunch 12:05-12:15 toileting 12:15-2:45 Nap pack 2:45-3:00 Toileting 3:00-3:30 Arena – snack 3:30-4:30 Structured Centers 4:30-5:30 Structured Centers

How long does your child tend to nap for? ______What time would you like to pick up your child? ______

Preschool Enrichment Program (3-5): 12:30-1:00 Lunch bunch (206/207) 1:00-2:45 Nap Pack OR 1:00-1:30 Free Play Playground 1:30-2:30 Structured Centers 2:30-3:30 Structured Centers/Snack 3:30-4:30 Structured Centers 4:30-5:30 Structured Centers www.StepByStepEDUPlay.com * 1814 14th Street * Santa Monica, CA 90404 Phone: 310-581-0590 * Fax: 310-581-0589 If your child is in a Step By Step preschool class, Which one is it? ______Does your child still nap? Yes/NO If yes, how long does your child tend to nap for? ______What time would you like to pick up your child? ______

Elementary Age Enrichment Program (5-9):

2:30-3:30 Structured Centers/Snack 3:30-4:30 Structured Centers 4:30-5:30 Structured Centers

Is your child being dropped off by public transportation or by a parent/caregiver? ______What school does your child attend? ______Is your child continuing their day after the Giraffes class? Yes/No What time would you like to pick up your child? ______

Middle School Age Enrichment Program (10-13):

3:30-5:00 homework help (tutoring)/Structured activities/off site field trips/free time

High School Age Enrichment Program (14-18):

3:30-5:00 homework help (tutoring)/ off site activities

www.StepByStepEDUPlay.com * 1814 14th Street * Santa Monica, CA 90404 Phone: 310-581-0590 * Fax: 310-581-0589 Step By Step Family Questionnaire

Who are you child's primary caregivers and what language(s) do they speak?

______

Briefly describe your child (likes & dislikes, personality, temperament): ______

Health History: (allergies, past/current medications, pregnancy complications, Dietary restrictions, food preferences, previous illnesses, any relevant past health history) ______

Self-help skills: (toileting, independent feeding, dressing, hygiene) ______

My child is allergic to: ______www.StepByStepEDUPlay.com * 1814 14th Street * Santa Monica, CA 90404 Phone: 310-581-0590 * Fax: 310-581-0589 Please list any other information about your child that would be important for Step by Step teachers to know: ______

Step by Step Medical Release/Field Trip (Park) Permission Form

I hereby give permission for my child to participate in the Step By Step activities and field trips, including community outings such as walks to the park or walks in the neighborhood. I hereby release and discharge Step by Step Early Childhood Development Program and each and all of their agents and employees from any liability whatsoever, resulting from, or in any manner arising out of any injury or damage which may be sustained because of my child’s participation in these activities.

Should it become necessary for my child to receive medical treatment while participating in these activities, I give Step by Step personnel permission to use their judgment in obtaining medical service for my child, and I give permission to the physician selected by the personnel to render medical treatment deemed necessary and appropriate by the physician.

I understand, and agree to the above.

Child’s Name:

Parent Print Name:

Parent/Guardian Signature:

Date: www.StepByStepEDUPlay.com * 1814 14th Street * Santa Monica, CA 90404 Phone: 310-581-0590 * Fax: 310-581-0589 Revised 5-13-09

Medical Release and Administering Medication Agreement

Should it become necessary for my child to receive medical treatment while participating in these activities, I give Step by Step personnel permission to use their judgment in obtaining medical service for my child, and I give permission to the physician selected by the personnel to render medical treatment deemed necessary and appropriate by the physician.

I, hereby give permission for Step By Step employees to administer medication to my child while they are participating in the program. Medications will be clearly labeled and a doctor’s note with instructions and a prescription will be given to the office manager prior to the first day of class. Enough medication for 72 hours will be kept on-site.

Name of Medication:______

Dosage Amount:______

Needs to be refrigerated? Please circle one: Yes No

I have read, understand and agree to the foregoing:

www.StepByStepEDUPlay.com * 1814 14th Street * Santa Monica, CA 90404 Phone: 310-581-0590 * Fax: 310-581-0589 Child’s Name:

Parent Name:

Parent Signature:

Waiver, Release and Indemnity Agreement (Permission to Photograph)

Student Name: ______

I hereby give permission for my child to be filmed, videotaped and/or photographed while participating in the Step by Step Playroom, community programs, home visits, and/or related activities.

I waive all rights to inspect or approve the finished project or products or the advertising copy of printed matter that may be used in connection with or the use to which it may be applied. I grant the right and permission to copyright, use, re-use, publish and republish videotapes and/or photographic portraits or pictures of my child, or pictures in which my child may be included, in whole or in part, or otherwise made through any media for art, advertising, trade or other purpose. I consent to the use of any printed matter in conjunction therewith.

As a condition of my child’s participation, I agree to waive all claims again Step by Step, its agents and employees, from any and all liability or claims, demands, losses, causes of action, suits or judgments of any kind whatsoever that I may have against Step by Step because of any personal injury, bodily injury, or property damage or loss that may arise out of or in any way be connected with the above-described activity.

______Parent/Guardian Signature

______Parent/Guardian Name (Please Print) Date

------ My child’s photographed can be posted for SBS classes + activities, but not for the website or outside publication www.StepByStepEDUPlay.com * 1814 14th Street * Santa Monica, CA 90404 Phone: 310-581-0590 * Fax: 310-581-0589  No, I do not wish to give permission for my child to be filmed, videotaped, or photographed.

Parent/Guardian Signature______

______Parent/Guardian Name (Please Print) Date

Agreement to Allow Services to be Provided Away from Child’s Residence Waiver and Release Liability Form

I give permission for my child to participate in the Step By Step playroom activities. I, hereby hold harmless, waive, release and discharge Step by Step Early Childhood Development Program and each and all of their agents and employees, from any and all liability or claims, demands, losses, causes of action, suits or judgments of any kind whatsoever resulting from, or in any manner arising out of, any injury or damage which may be sustained because of my child’s participation in these activities with Step by Step Early Childhood Development Program.

I have read, understand and agree to the foregoing:

Child’s Name:

Parent Name:

Parent Signature:

www.StepByStepEDUPlay.com * 1814 14th Street * Santa Monica, CA 90404 Phone: 310-581-0590 * Fax: 310-581-0589 SICK POLICY Health and Safety: It is important that current health, medical and other developmental information is shared with Step by Step in order to best meet your child’s needs. The information is gathered through parent reports and collateral reports provided by the parent or through agreement with other agencies. All reports are confidential and not shared without the parents’ written permission.

If, during a session, the Facilitator/Interventionist feels that the child is ill, she/he will discontinue the session and the session will be billed. This is necessary because if the child is contagious and the facilitator becomes ill, she/he may miss more visits and put other children at risk. Some children have compromised immune systems and a simple cold may become very serious. In addition, if a child does not feel well (e.g., is lethargic), Step By Step will call the caregiver to come pick them up since they cannot participate in the class activities. If your child has any of the following symptoms, we ask that you please cancel your child’s session. In order to return to school, we ask that you provide a doctor’s note that your child is no longer contagious and they are well enough to come back to school when it is a chronic illness.

 Fever accompanied by other symptoms, temperature of 100 degrees taken by mouth or under arm, or 101 degrees taken by ear or rectally.  Any rash suspicious of contagious childhood disease.  Vomiting accompanied by other symptoms (fever, rash, diarrhea, crankiness, etc.)  Diarrhea accompanied by other symptoms (fever, vomiting, rash, crankiness, etc.) or uncontrolled diarrhea (stool runs out of diaper or child is unable to get to the toilet in time).  Any skin rash, lesion or wound with bleeding or oozing of clear fluid or pus.  Conjunctivitis, also called pink eye, with white or yellow discharge.  Mouth sores or uncharacteristic drooling.  Any condition which prevents the child from participating comfortably in usual program activities  Scabies, head lice or other infestations.  Constant, uncontrolled nasal discharge or constant uncontrolled productive cough (raising phlegm). Please sign and return the extra copy of this page to the Step by Step office. I have read, understand and agree to the foregoing:

Child Name: Parent Name:

Parent Signature: Date:

www.StepByStepEDUPlay.com * 1814 14th Street * Santa Monica, CA 90404 Phone: 310-581-0590 * Fax: 310-581-0589 Emergency Information Sheet

Date of Birth Age NAME - Last First Middle PARENTS: ADDRESS: PHONE: Home Cell Other DIAGNOSIS: PHYSICIAN OFFICE OTHER PHYSICIANS OFFICE Local Emergency Contact: NAME RELATIONSHIP PHONE NAME RELATIONSHIP PHONE Out of Area Emergency Contact: NAME RELATIONSHIP PHONE Persons Authorized for Pick-up: 1.NAME: RELATIONSHIP: PHONE ___ 2 3 Presently taking medication? Y or N Daily? Y or N If yes, name medicine and when taken: Is Child Toilet Trained? Y or N Explain: Allergies: Diet Restrictions: Are Immunizations/Vaccinations up to date? Yes No If No, Why? Please check if currently or previously applies: Allergies Vision Problem Encephalitis Sensory Concerns Asthma Wears Glasses Hepatitis Behavioral Concerns Chicken Pox Speech Disorder Bites Difficulty Focusing Seizures Hearing Difficulty Transitioning Communication Concerns Problem Diabetes Heart Disorder Problems with Safety Concerns Discipline Drug Reactions Eczema Has Tantrums Difficulty Following Directions

www.StepByStepEDUPlay.com * 1814 14th Street * Santa Monica, CA 90404 Phone: 310-581-0590 * Fax: 310-581-0589 In the event of a Medical Emergency and I cannot be reached, I hereby give permission for my child to be transported to a medical facility for emergency care and give permission to the physician or dentist. Parent/Guardian Signature Date

www.StepByStepEDUPlay.com * 1814 14th Street * Santa Monica, CA 90404 Phone: 310-581-0590 * Fax: 310-581-0589