<p> EARLY CHILDHOOD PROGRAM Form 1. CHILD'S FACE SHEET/ENROLLMENT FORM</p><p>CHILD INFORMATION Child's Name: ______Date of Birth: ______Home Address: ______Reachable Phone: ______School attending for 2016/17 school year: ______Primary Language: ______Child's Identifying Information (required by the Department of Early Education and Care): Eye Color: ______Hair Color: ______Sex: ______Height: ______Weight: ______Skin Color: ______Identifying Marks: ______</p><p>PARENT/GUARDIAN INFORMATION</p><p>Parent/Guardian Name: ______Parent/Guardian Name: ______Relationship to Child: ______Relationship to Child: ______Home Address: ______Home Address: ______Home Telephone: ______Home Telephone: ______Mobile Phone: ______Mobile Phone: ______Preferred Email: ______Preferred Email:______Secondary Email: ______Secondary Email: ______Work Name/Address: ______Work Name/Address : ______Work Telephone: ______Work Telephone: ______Hours at Work: From:______To:______Hours at Work: From:______To:______</p><p>CHILD'S PHYSICIAN & MEDICAL INFORMATION Physician Name: ______Telephone Number: ______Address: ______Fax Number: ______Allergies/Special Diet: Yes____ No_____ (If yes, explain) ______Individual Health Plan for child with a chronic health condition? Yes_____ No_____ (if yes, please attach) Copies of any custody agreements, court orders, and restraining orders pertaining to the child? Yes___No___ 1 (if yes, please attach______Special Limitations or Concerns: Yes___ No___ (If yes, explain)______By signing below, I have read and understand the contents of this page.</p><p>Parent/Guardian Signature: ______Date ______</p><p>FOR WCCC USE: Date of Admission: ______Age at Admission: ______Classroom: ______</p><p>Form 2. DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION (Page 1)</p><p>Child’s Name: ______Date of Birth: ______</p><p>Regulations for licensed child-care facilities require this information to be on file to address the needs of children while in care. Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child. </p><p>DEVELOPMENTAL HISTORY</p><p>Age began sitting: ______crawling: ______walking: ______talking: ______*Does your child pull up? ______*Crawl? ______*Walk with support? ______Any speech difficulties? ______Special words to describe needs ______Language spoken at home ______*Any history of colic? ______*Does your child use pacifier or suck thumb? ______*When? ______*Does your child have a fussy time? ______*When? ______*How do you handle this time? ______</p><p>HEALTH </p><p>Any known complications at birth? ______2 Serious illnesses and/or hospitalizations:______Special physical conditions, disabilities:______Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions: ______Regular medications: ______</p><p>EATING HABITS </p><p>Special characteristics or difficulties: ______*If infant is on a special formula, describe its preparation in detail: ______Favorite foods: ______Foods refused: ______* Is your child fed held in lap?______High chair?______* Does your child eat with spoon?______Fork?______Hands?______</p><p>TOILET HABITS </p><p>*Are disposable or cloth diapers used? ______*Is there a frequent occurrence of diaper rash?______*Do you use: oil:______powder:______lotion:______other:______*Are bowel movements regular?______How many per day? ______*Is there a problem with diarrhea?______Constipation? ______*Has toilet training been attempted? ______*Please describe any particular procedure to be used for your child at the center: ______</p><p>DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION (Page 2)</p><p>TOILET HABITS (cont.) *What is used at home? Pottychair? ______Special child seat? ______Regular seat? ______*How does your child indicate bathroom needs (include special words): ______3 Is your child ever reluctant to use the bathroom? ______Does your child have accidents? ______SLEEPING HABITS</p><p>*Does your child sleep in a crib? ______Bed? ______Does your child become tired or nap during the day (include when and how long)? ______Please note: The American Academy of Pediatrics has determined that placing a baby on his/her back to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and unexplained death of a baby under one year of age. If your child does not usually sleep on his/her back, please contact your pediatrician immediately to discuss the best sleeping position for your baby. Please also take the time to discuss your child’s sleeping position with your caregiver. When does your child go to bed at night? ______and get up in the morning? ______Describe any special characteristics or needs (stuffed animal, story, mood on waking etc) ______SOCIAL RELATIONSHIPS How would you describe your child? ______Previous experience with other children/day care:______Reaction to strangers:______Able to play alone? ______Favorite toys and activities: ______Fears (the dark, animals, etc.):______How do you comfort your child? ______What is the method of behavior management/discipline at home? ______What would you like your child to gain from this childcare experience? ______DAILY SCHEDULE Please describe your child’s schedule on a typical day. For infants, please include awakening, eating, time out of crib/bed, napping, toilet habits, fussy time, night bedtime, etc. ______4 ______Is there anything else we should know about your child? ______</p><p>Parent/Guardian Signature ______Date ______</p><p>EARLY CHILDHOOD PROGRAM Form 5. HEALTH CARE, EVACUATION, & PARENT HANDBOOK/POLICIES CONSENT FORM</p><p>Child’s Name______Date of </p><p>Birth______</p><p>Parent/Guardian Name______Reachable </p><p>Phone______</p><p>Parent/Guardian Name______Reachable </p><p>Phone______</p><p>FIRST AID AUTHORIZATION I authorize WCCC teachers who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate as well as have access to health information in my child’s file. I give WCCC permission to post my child’s allergy as needed.</p><p>EMERGENCY MEDICAL CARE I understand that every effort will be made to contact me in the event of an emergency requiring medical treatment, including but not limited to an epinephrine auto-injection for suspected exposure to a life threatening allergen for my child when delay would be dangerous to the health of my child. If I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to ______, and to secure necessary medical treatment for my child. Physician Name ______Address______Phone </p><p>Number______</p><p>Health Insurance Coverage: ______Policy # 5 ______</p><p>Child’s </p><p>Allergies______</p><p>Chronic Health conditions______</p><p>EMERGENCY EVACUATION In the case of a catastrophic emergency, I give WCCC permission to transport my child by reasonable means to a location deemed appropriate by WCCC, Town of Wellesley police or fire departments or Wellesley College campus police. I understand I will be notified as soon as possible.</p><p>PARENT HANDBOOK/POLICIES AGREEMENT</p><p>I am aware that the WCCC Parent Handbook/Policies are located on the WCCC website Early Childhood Policies page, and acknowledge that I am responsible for knowing the contents. </p><p>The link can be found at: http://www.wccc.wellesley.edu Early Childhood Policy Tab</p><p>By signing below, I have read and understand the contents of this page.</p><p>Parent/Guardian Signature ______Date______EARLY CHILDHOOD PROGRAM Form 6. PICK UP CONSENT & TRANSPORTATION FORM</p><p>Child’s Name: ______My child will arrive at the program by: ___ Parent Drop Off ___ Public/Private/Contract Van ___ Private Transportation arranged by parent Other: ______My child will depart from the program by: ___ Parent Drop Off ___ Public/Private/Contract Van ___ Private Transportation arranged by parent Other: ______PICK UP LIST (in order to be contacted in the case of an emergency) We must have written authorization from you to allow another person to pick up your child. We 6 cannot accept phone calls for pick-up authorization. It is our policy to request photo identification from anyone unfamiliar to us. Please inform those on your pick-up list that we must have proper photo identification in order to release your child.</p><p>I give permission for the following people to pick up my child from WCCC in an emergency or when I notify the program: 1. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______2. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______3. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______4. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______By signing below, I have read and understand the contents of this page.</p><p>Parent/Guardian Signature ______Date______</p><p>7 5. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______6. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______7. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______8. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______9. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______10. Name______Physical Description______Address:______Relationship to Child:______8 Home Phone #______Work Phone #______Cell Phone #______11. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______12. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______13. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______14. Name______Physical Description______Address:______Relationship to Child:______Home Phone #______Work Phone #______Cell Phone #______</p><p>By signing below, I have read and understand the contents of this page.</p><p>Parent/Guardian Signature ______Date______</p><p>EARLY CHILDHOOD PROGRAM</p><p>9 Form 7. OFF SITE CONSENT, FIELD TRIP, ORAL HEALTH, UPBUP PERMISSION FORM</p><p>Child’s Name: ______</p><p>OFF-SITE ACTIVITIES PERMISSION I give permission for my child to walk accompanied by WCCC teachers to the following off-site locations:</p><p>Wellesley College Linden Street Shops and Restaurants Wellesley Downtown Area Shops and Dana Hall School Restaurants Tenacre Country Day School Wellesley Fire Station Whole Foods Wellesley Public Library Hunnewell School Playground Wellesley Brook Path Wellesley Duck Pond</p><p>FIELD TRIP PERMISSION You have my permission to take my child on trips that the Wellesley Community Children’s Center plans. I understand that I will be notified in writing of all trips requiring transportation in advance. I also understand that all necessary precautions will be taken to ensure his or her safety, and I will not hold the Wellesley Community Children’s Center responsible for any accident, which may occur on such a trip.</p><p>ORAL HEALTH PERMISSION In January 2010, EEC issued new regulations for child care programs that include a requirement that educators assist children with brushing their teeth if children are in care for more than four hours or if children have a meal while in care [606 CMR 7.11(11)(d]. This regulation is intended to:</p><p> Help children learn about the importance of good oral health  Provide information and resources regarding good oral health to child care programs and families  Help address the high incidence of tooth decay among young children in Massachusetts, which is associated with numerous health risks. EEC licensed programs must comply with this regulation. However, parents of children, who are brushing their teeth at home, may choose that their child (ren) not participate in tooth brushing while present at the childcare program. Please check one of the following: ______I do not wish to have my child participate in tooth brushing while in care at Wellesley Community Children’s Center.</p><p>______I would like to have my child participate in tooth brushing while in care at Wellesley Community Children’s Center 10 UPBUP INFORMATION SHARING WCCC shares the contents of this Child Enrollment Packet with UpBup when necessary. By submitting information, you acknowledge that UpBup may be involved in processing, storing, and organizing this information. UpBup is required by contract with WCCC to keep your personally identifiable information confidential. By signing below, I have read and understood the contents of this page. </p><p>Parent Signature: ______Date: ______</p><p>EARLY CHILDHOOD PROGRAM Form 8. PHOTO, OBSERVER, CONTACT, HEALTH ACCESS PERMISSION/CONSENT FORM</p><p>Child’s Name: ______</p><p>PHOTO PERMISSION/WEBSITE PERMISSION</p><p>Throughout the year various newspapers and magazines ask to photograph the children while they are at WCCC. Pictures might include walks, parties, or a child playing indoors or outside. Please check below.</p><p>______I give permission for my child to be photographed while attending WCCC.</p><p>______I do not wish my child to be photographed while attending WCCC.</p><p>The WCCC website includes some photographs of children at play. The children are not identified by name, age or classroom. Photographs will be shown to parents before they are mounted on the site.</p><p>______I give permission for my child’s photograph to be used on the WCCC website.</p><p>______I do not wish my child’s photograph to be used on the WCCC website.</p><p>OBSERVER PERMISSION WCCC hosts observers throughout the year from other children’s centers, colleges, high schools, and the community, as well as our own consultants. The Massachusetts Department of Early Education and Care requires that parents sign a general consent form to indicate their awareness that observers are permitted at the Early Childhood Program. Observers are scheduled by the Director so as not to interfere with the children’s program and general after school program routines. Observers may not interact with any child unless special consent from parents is obtained in writing and a detailed description of the interaction is furnished to parents. </p><p>EMAIL, ADDRESS & PHONE LIST PERMISSION</p><p>11 Each year WCCC distributes a list to families currently enrolled in their child's classroom, which includes each family's home address, home phone number, and email addresses. This is a private list and we ask that it be used only for personal contact purposes. Please check below: ______I want to be included in WCCC's list of families.</p><p>______I do not want to be included in WCCC's list of families. HEALTH SCREENING ACCESS ______My child’s health care provider offers access to the following screenings: Developmental, Mental Health, Health, Nutrition, Vision and Hearing.</p><p>______My child’s health care provider does not offers access to the following screenings: Developmental, Mental Health, Health, Nutrition, Vision and Hearing.</p><p>By signing below, I have read and understand the contents of this page.</p><p>Parent/Guardian Signature ______Date ______</p><p>EARLY CHILDHOOD PROGRAM Form 9. PERMISSION FOR SUNSCREEN, INSECT REPELLENT, OVER THE COUNTER CREAMS AND OINTMENTS</p><p>Child’s Name: ______</p><p>The Department of Early Education and Care requires parental permission for teachers to apply sunscreen, insect repellent, diaper cream, petroleum jelly and other non-prescription ointments which are not applied to open wounds, open rashes, or broken skin. Using the list below, parents should give permission only for the age appropriate items that they anticipate their child will need. Parents can discuss any special instructions regarding the application of these products, when they give the cream/ointment in the original container to their child’s teacher.</p><p>I give permission for the WCCC teachers to apply the following over-the-counter items to my child:</p><p>Sunscreen: (Yes) ______(No) ______</p><p>*Preschool teachers will provide information about a plan in which preschool parents contribute money to purchase one type of sunscreen that is used for the entire class.</p><p>Insect Repellent: (Yes) ______(No) ______</p><p>Diaper Cream: (Yes) ______(No) ______</p><p>Petroleum Jelly: (Yes) ______(No) ______12 ______: (Yes) ______(No) ______</p><p>______: (Yes) ______(No) ______</p><p>______: (Yes) ______(No) ______</p><p>______: (Yes) ______(No) ______</p><p>______: (Yes) ______(No) ______</p><p>______: (Yes) ______(No) ______</p><p>By signing below, I have read and understand the contents of this page.</p><p>Parent/Guardian Signature ______Date ______</p><p>13</p>