Form 1. CHILD's FACE SHEET/ENROLLMENT FORM
EARLY CHILDHOOD PROGRAM
Form 1. CHILD'S FACE SHEET/ENROLLMENT FORM
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: ______
PARENT/GUARDIAN INFORMATION
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Parent/Guardian Name: ______
Relationship to Child: ______
Home Address: ______
Home Telephone: ______Mobile Phone: ______
Preferred Email: ______
Secondary Email: ______Work Name/Address: ______
Work Telephone: _______
Hours at Work: From:______To:______
Parent/Guardian Name: ______
Relationship to Child: ______
Home Address: ______
Home Telephone: ______Mobile Phone: ______
Preferred Email:______
Secondary Email: ______Work Name/Address : ______
Work Telephone: ______
Hours at Work: From:______To:______
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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___
(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.
Parent/Guardian Signature: ______Date ______
FOR WCCC USE: Date of Admission: ______Age at Admission: ______Classroom: ______
Form 2. DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION
(Page 1)
Child’s Name: ______Date of Birth: ______
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.
DEVELOPMENTAL HISTORY
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? ______
HEALTH
Any known complications at birth? ______
Serious illnesses and/or hospitalizations:______
Special physical conditions, disabilities:______
Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions: ______
______
______
Regular medications: ______
EATING HABITS
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?______
TOILET HABITS
*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: ______
______
DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION
(Page 2)
TOILET HABITS (cont.)
*What is used at home? Pottychair? ______Special child seat? ______Regular seat? ______
*How does your child indicate bathroom needs (include special words): ______
Is your child ever reluctant to use the bathroom? ______
Does your child have accidents? ______
SLEEPING HABITS
*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. ______
______
______
______
Is there anything else we should know about your child? ______
______
______
Parent/Guardian Signature ______Date ______
EARLY CHILDHOOD PROGRAM
Form 5. HEALTH CARE, EVACUATION, &
PARENT HANDBOOK/POLICIES CONSENT FORM
Child’s Name______Date of Birth______
Parent/Guardian Name______Reachable Phone______
Parent/Guardian Name______Reachable Phone______
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.
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 Number______
Health Insurance Coverage: ______Policy # ______
Child’s Allergies______
Chronic Health conditions______
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.
PARENT HANDBOOK/POLICIES AGREEMENT
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.
The link can be found at: http://www.wccc.wellesley.edu Early Childhood Policy Tab
By signing below, I have read and understand the contents of this page.
Parent/Guardian Signature ______Date______
EARLY CHILDHOOD PROGRAM
Form 6. PICK UP CONSENT & TRANSPORTATION FORM
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 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.
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.
Parent/Guardian Signature ______Date______
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:______
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 #______
By signing below, I have read and understand the contents of this page.
Parent/Guardian Signature ______Date______
EARLY CHILDHOOD PROGRAM
Form 7. OFF SITE CONSENT, FIELD TRIP, ORAL HEALTH, UPBUP PERMISSION FORM
Child’s Name: ______
OFF-SITE ACTIVITIES PERMISSION
I give permission for my child to walk accompanied by WCCC teachers to the following off-site locations:
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Wellesley College
Wellesley Downtown Area Shops and Restaurants
Wellesley Fire Station
Wellesley Public Library
Wellesley Brook Path
Wellesley Duck Pond
Linden Street Shops and Restaurants
Dana Hall School
Tenacre Country Day School
Whole Foods
Hunnewell School Playground
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FIELD TRIP PERMISSION
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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.
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:
· 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.
______I would like to have my child participate in tooth brushing while in care at Wellesley Community Children’s Center
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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.
Parent Signature: ______Date: ______
EARLY CHILDHOOD PROGRAM
Form 8. PHOTO, OBSERVER, CONTACT, HEALTH ACCESS PERMISSION/CONSENT FORM
Child’s Name: ______
PHOTO PERMISSION/WEBSITE PERMISSION
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.
______I give permission for my child to be photographed while attending WCCC.
______I do not wish my child to be photographed while attending WCCC.
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.
______I give permission for my child’s photograph to be used on the WCCC website.
______I do not wish my child’s photograph to be used on the WCCC website.
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.
EMAIL, ADDRESS & PHONE LIST PERMISSION
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.
______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.
______My child’s health care provider does not offers access to the following screenings:
Developmental, Mental Health, Health, Nutrition, Vision and Hearing.
By signing below, I have read and understand the contents of this page.
Parent/Guardian Signature ______Date ______
EARLY CHILDHOOD PROGRAM
Form 9. PERMISSION FOR SUNSCREEN, INSECT REPELLENT,
OVER THE COUNTER CREAMS AND OINTMENTS