mercy child development center & preschool...mercy child development center & preschool...
TRANSCRIPT
1 per child
Mercy Child Development Center & PreschoolEnrollment Information
Child’s Information
Father’s Information
Mother’s Information
Marital status of parents: Married______ Divorced_____ Single______ Separated_____ Foster Parent______ In cases other than married with who does the child reside: _________________________________________
Insurance Information-Must be completed.
By checking this box and typing your name in the signature field, you are stating that the information you'veprovided herein is true and correct to the best of your knowledge.
Signature: Date:
Does your child have health insurance? ____Yes, Company _______________ ID#___________________
Does your child have dental insurance? ____Yes, Company________________ ID#___________________
_____No we do not have health insurance _____ No we do not have dental insurance
Name: ___________________________________ Primary Email Address: _________________________
Home Address: ____________________________ City: ________________ State: ______ Zip: ________
Home Phone: ____________________ Cell Phone: ___________________ Cell Carrier: ______________
Employer: _________________________ Dept: ____________ Work Phone: _______________________
Child’s Full Name: ________________________________________________Nickname: ______________
Birth Date: _________ Sex: ____ Start Date: __________________ School (if school age): _____________
Please list all Allergies: ___________________________________________________________________
*MUST INCLUDE A COPY OF CHILD'S BIRTH CERTIFICATE FOR FILE (All but school age)____
Name: ___________________________________ Primary Email Address: _________________________
Home Address: ____________________________ City: ________________ State: ______ Zip: ________
Home Phone: ____________________ Cell Phone: ___________________ Cell Carrier: ______________
Employer: _________________________ Dept: ____________ Work Phone: _______________________
(one per family required)
(one per family required)
Medical/Dental Consent
In the event reasonable attempts to contact the parent/guardian have been unsuccessful, I,____________________________(Mother/Father) of_________________________, do hereby give my permission to the personnel of Mercy Child Development Center & Preschool, to secure and authorize such emergency medical/dental care and /or treatment at _______________(*hospital of choice) as my child might require while under supervision of the Child Development Center. I agree to pay all costs and fees contingent on any emergency treatment needed for my child as secured and authorized under this consent. This authorization shall remain effective during the entire period that aforesaid minor is enrolled at Mercy Child Development Center & Preschool.
*Physician & Dentist must be listed.
________________________ ___________________________________ ____________________ Physicians name City, State Phone ________________________ ___________________________________ ____________________ Dentists name City, State Phone
Screening Information: Does your child visit a dentist: yes___ no___ Had a Lead Test: yes___ no___If yes please provide the date of the last screening. Dental: ____________ Lead: ____________(Regardless of whether or not your child has had a dental screening you must list a dental provider above.)
*If you wish for your child to be treated at a hospital other than Mercy, we will contact you so that you may make arrangements for transportation. In the event of a situation that we judge to be an emergency, the child will be taken to Mercy Medical Center Emergency room.
Emergency Contact and Authorized Pick Up Persons
Please list persons to contact in the event parents cannot be reached and are authorized to pick up child: It is the responsibility of the parents to notify the center, in writing, of any changes.
Signature: ___________________________________________________ Date: _________________
Are there any custody orders or restraining orders for persons who may attempt to pick up or have contact with the child while in care at the center? Are there any people that may NOT pick up your child? Name: __________________________________Name:__________________________________
1st Contact/Pick up Is this person over 18 years of age? ______yes _______no Name: __________________________________ Relationship to child: ______________________ Home Phone: ________________ Work Phone: _______________ Cell Phone: _______________
2nd Contact/Pick up Is this person over 18 years of age? ______yes _______no Name: __________________________________ Relationship to child: ______________________ Home Phone: ________________ Work Phone: _______________ Cell Phone: _______________
3rd Contact/Pick up Is this person over 18 years of age? ______yes _______no Name: __________________________________ Relationship to child: ______________________ Home Phone: ________________ Work Phone: _______________ Cell Phone: _______________
4th Contact/Pick up Is this person over 18 years of age? ______yes _______no Name: __________________________________ Relationship to child: ______________________ Home Phone: ________________ Work Phone: _______________ Cell Phone: _______________
If at any time the center does not feel comfortable releasing your child to a pick up person, the parent will be notified to make other arrangements. Mercy does not assume responsibility for care once the child is released to an authorized pick up person.
Address
Address
By checking this box and typing your name in the signature field, you are stating that the information you've provided herein is true and correct to the best of your knowledge.
Mercy Child Development Center & Preschool Permission Slip
Community Participation
Media
Sunscreen
Parent Handbook
As a parent, I understand I have the right to change this at any time and can do so by completing a new permission slip.
Signature_________________________________________Date_________________
I _____________________ (parent) understand it is my responsibility to read and abide by all Mercy Child Development Center policies contained in the Parent Handbook. The handbook can be found at mercydubuque.com/parentinformation. I understand that Mercy CDC reserves the right to unilaterally change, modify, amend, add, rescind or terminate any or all Child Development Center policies, at any time, with our without notice, as it determines appropriate in its sole discretion. I further acknowledge that failure to comply with policies and procedures of the CDC may result in removal of my children from the Mercy Medical Center CDC.
I give permission for Mercy Child Development Center & Preschool staff to apply a sunscreen of SPF 30 or higher to my child (age 6 months or older) as specified below for outdoor activities.
I do not know of any allergies my child has to sunscreen. Staff may use the sunscreen of their choice following the directions or recommendations printed on the bottle. My child is allergic to some sunscreens. Please use only the following brand sunscreen I have provided________________________________________. For medical or other reasons, please do not apply sunscreen to the following areas of my child’s body: _________________________________________.
I do___/do not___give permission for my child ________________________________ to be photographed or video taped by autho rized person of Mercy Child Development Center & Preschool. If photos are used for any purpose other then within the center parents will be contacted for specific permission.
As part of our educational program in the preschool classrooms, the children may occasionally be taken on field trips away from Mercy Child Development Center. These trips may include scenic walks and bus rides to points of interest. These excursions will help broaden the preschooler’s experiences and knowledge.
When my child is age appropriate I do____/do not ____ give permission for my child ______________________________to go on community events, activities, or field trips.
By checking this box and typing your name in the signature field, you are stating that theinformation you've provided herein is true and correct to the best of your knowledge.
Mercy Child Development Center & Preschool Secured Access Information Form
Mercy Child Development Center & Preschool’s secured access system requires that each authorized user have an access “touch chip” in order to be able to enter the Center. Each family will be issued a maximum of two chips. In most cases, one chip will be assigned to each parent. If your situation is that one parent primarily drops off and picks up the children and that another adult who is not the parent, (grandma or nanny for example) also frequently and consistently picks up the children, then you may ask to have that individual assigned an access chip instead of a parent. Please keep in mind that the system is designed to limit access to the Center, so authorization given to those other than parents should be considered carefully.
Adults who need access to the Child Development Center & Preschool on an infrequent basis, will need to call into the Center on a courtesy phone and be given clearance before being able to enter the Center.
Please complete the following information. PLEASE PRINT!!
Child’s/children’s names_____________________________________________________________
Two (2) access chips will be authorized to each family. Complete the following information for those who you would like to have authorized for access.
Mother’s name____________________________________ last four of social security # __________
Father’s name____________________________________ last four of social security # __________
If there is another adult who has frequent and consistent responsibility for picking up the children, you may wish for them to be given an access chip. Please keep in mind that if you wish them to have authorization, then only one parent will be able to have an access chip.
Name___________________________________________ last four of social security # __________
Relationship to child________________________________________________________________
Signature___________________________________________________Date__________________
By checking this box and typing your name in the signature field, you are stating that the information you've provided herein is true and correct to the best of your knowledge.
Request for Electronic Communication Agreement
Daily communication through HiMama or other electronic program: Mercy Child Development Center & Preschool (MCDC) can now deliver daily communication regarding each child’s daily activities, meals, toileting and so much more. MCDC will be delivering all communication through this form, unless you choose to opt out. MCDC has partnered with HiMama to provide an online and app version of daily communication. HiMama has a Secure Sockets Layer (SSL) certificate, ensuring all data passed between the HiMama server and your browser remains private. However, with any data system there may be risks associated with the technology and it could be hacked and or have a security compromise. MCDC will retain all log in information and passwords in a secure location and the information will not be shared by Management outside the agency. MCDC staff monitors system security notices and updates per information provided. By signing this agreement you are providing consent that you are willing to accept the risk associated with the product that staff use and you will hold MCDC harmless should a breach occur.
Note that sometimes other children in the center may feature in photos, videos or stories of your child. By giving your consent you agree not to share photos or videos of any child, other than your own, outside MCDC without permission.
How to withdraw Consent: You may withdraw your consent to receive communication in electronic form by updating this form at any time. At that point you will no longer receive updates through HiMama and will be given a paper version of daily communication.
___ I request that daily communications from MCDC be delivered to me through HiMama or other electronic program. I understand that this form of communication may have risks associated with it including security, creating a risk of improper disclosure to unauthorized individuals. I am willing to accept this risk, and will not hold MCDC responsible should such incident occur.
___ I elect to opt out of daily communication through HiMama, by checking this I understand that MCDC will not communicate with me through HiMama, unless I sign an agreement in the future.
Name of Child/Children: _______________________________________________________________________
Email:
To link your electronic daily communication we will use the emails currently on file. You will receive an email
confirming this communication through HiMama with directions for signing on. If you wish to use a different
email or add an additional email please include them below.
Name: _________________________________ Email Address: ________________________________________
Name: _________________________________ Email Address: ________________________________________
By checking this box and typing your name in the signature field, you are stating that the information you've provided herein is true and correct to the best of your knowledge.
Parent Signature: ______________________________________________Date: _________________________
___
The U.S. Department of Agriculture prohibits
discrimination against its customers, employees,
and applicants for employment on the bases of
race, color, national origin, age, disability, sex,
gender identity, religion, reprisal, and where
applicable, political beliefs, marital Status,
familial or parental status, sexual orientation, or
all or part of an individual’s income is derived
from any public assistance program, or protected
genetic information in employment or in any
program or activity conducted or funded by the
Department. (Not all prohibited bases will apply
to all programs and/or employment activities.)
If you wish to file a Civil Rights program
complaint of discrimination, complete the USDA
Program Discrimination Complaint Form, found
online at
http://www.ascr.usda.gov/complaint_filing_cust.h
tml. Or at any USDA office, or call (866)632-
9992 to request the form. You may also write a
letter containing all of the information requested
in the form. Send your completed complaint
form or letter to us by mail at U.S. Department of
Agriculture, Director, Office of Adjudication,
1400 Independence Avenue, S.W., Washington,
D.C. 20250-9410, by fax (202)690-7442 or email
Individuals who are deaf, hard of hearing or have
speech disabilities may contact USDA through
the Federal Relay Service at (800) 877-8339; or
(800) 845-6136 (Spanish).
Iowa Department of Education Bureau of Nutrition and Health Services
400 E. 14th St., Grimes State Office Building Des Moines, Iowa 50319-0146
Phone: (515) 281-5356
Contacts
If you are a parent of children receiving child care or a
child care facility interested in participating in the CACFP,
or have questions about the Program, contact USDA at (703) 305-2590 or the Iowa State agency at:
Iowa Department of Education
Bureau of Nutrition and Health Services Grimes State Office Building
Des Moines, Iowa 50319-0146
Phone: (515) 281-5356
Iowa Nondiscrimination Statement: “It is the policy of this CNP provider not to discriminate on
the basis of race, creed, color, sex, sexual orientation, gender identity, national origin, disability, age, or religion
in its programs, activities, or employment practices as
required by the Iowa Code section 216.6, 216.7, and 216.9. If you have questions or grievances related to
compliance with this policy by this CNP Provider, please
contact the Iowa Civil Rights Commission, Grimes State Office Building, 400 E. 14th St. Des Moines, IA 50319-
1004; phone number 515-281-4121, 800-457-4416;
website: https://icrc.iowa.gov/.”
3.2 million children and almost 112,000 older adults
Iowa Department of Education Bureau of Nutrition and Health Services
400 E. 14th St., Grimes State Office Building Des Moines, Iowa 50319-0146
Phone: (515) 281-5356
Each day, more than 3.2 million children and 112,000 older adults participate in CACFP. Through CACFP, participants’ nutritional needs are met on a daily basis. The program plays a vital role in improving the quality of child care and making it affordable for many low-income families.
1 per child
Iowa Child and Adult Care Food Program
Child Care Enrollment Form
Times of Care Regular Days of Care Meals Served During Care Ethnicity/Race*
Last Name, First Name
Date of Birth Arrival Departure
M T W Th F S S B AM Sn
Lu PM Sn
D E Sn Ethnicity Race
*Ethnicity (Select one and enter in the chart above): H=Hispanic or Latino or N=Not Hispanic or LatinoRace (Select one or more and enter in the chart above): W=White, B=Black or African American, I=American Indian or Alaska Native, A=Asian, and P=Pacific IslanderThis information is requested by the Federal Government in order to monitor compliance with civil rights law. You are not required to furnish this information, but are encouraged to do so. The lawrequires that a program recipient may neither discriminate on the basis of this information nor on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations, thisprogram representative is required to note race/ethnicity on the basis of visual observation or surname.
Infants only (0 to 12 months): I am not enrolling an infant (skip this section)
As a participant in a USDA Child Nutrition Program, our center offers meals to children of all ages. Infant feeding is based on current nutrition guidelines. Infant foods are appropriate for the age and developmental readiness of your infant. Please select (X ) your choice(s) of the following options that will fulfill your infant’s food needs.
I will provide breast milk for my infant. Center formula may be used to supplement feedings if necessary: Yes No
I will provide infant formula for my infant. Name of formula:
I accept the center’s formula for my infant. Name of formula:
I will provide a statement from a medical authority for non-reimbursable formula. Name of formula: ____________________________________
I accept the center’s solid foods (appropriately textured) to be served to my infant as s/he is ready for them, and after I have discussed it with the caregiver.
I will provide solid foods for my infant*. The center may supplement with additional solid foods when my infant needs them: Yes No
*Meals cannot be reimbursed by the CACFP when parents provide solid foods except for medical reasons. DHS licensed centers are required to follow CACFP infant meal pattern
requirements regardless of who supplies the food. Your center can provide a copy of the CACFP infant meal pattern and a list of reimbursable foods upon request.
USDA is an equal opportunity provider and employer.
By checking this box and typing your name in the signature field, you are stating that the information you've provided herein is true and correct
to the best of your knowledge.
Signature: Date:
Your child is enrolled for care in a child care center that participates in the Child and Adult Care Food Program (CACFP). By participating in this Program, the center is meeting Federal meal pattern requirements and receiving reimbursement to assist with food costs. The CACFP requires that parents provide CACFP enrollment information on an annual basis. This form will be placed in our files and treated as confidential information.
Similac Isomil
Revised 6/2014
Women, Infants and Children (WIC) WIC Income Eligibility Guidelines