sleepin habits community action, inc family day care … · from the childcare home (i.e.--indicate...

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SLEEPING HABITS

Does your child sleep in a crib? Yes No Bed? Yes No 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 physician immediately to discuss the best sleeping position for your baby. Please also take the time to discuss your child’s sleeping position with your educator. Your educator will place your infant on his/her back unless there is a written physician’s order that specifies otherwise.

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 upon waking etc) ____________________

____________________________________________________________________________________________

SOCIAL RELATIONSHIPS

How would you describe your child? Shy Insecure Outgoing Talkative Aggressive

Other Explain__________________________________________________________________________

Previous experience with other children/child 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: ____________________________________

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, nightbedtime, etc. ________________________________________________________________________________________

________________________________________________________________________________________

Is your child involved with any other agency such as Early Intervention? Yes No

Please Explain____________________________________________________________________________

Is your child enrolled with WIC? Yes No If No, can we forward information concerning enrollment to a WIC outreach worker and also to other programs

offered by Community Action, Inc.? Yes No

Parent/Guardian Signature: __________________________________ Date: _____________________

Child’s Name _________________________________

Serving Children and Families for over 40 years.

Release of Information I authorize CAI Family Day Care (FDC) staff and FDC educator, and the persons or agencies listed below to mutually share information, including reports and evaluations that have been generated regarding my child or self. ________________________________________________ D.O.B._______________ Child’s Name ________________________________________________ Date ________________ Parent’s/Guardian’s Signature

**** Indicate authorization by initialing below**** **** Pediatrician’s name and address are required for all children****

______ Pediatrician ________________________________________________________________ (Name) (Address) ______ Dentist ________________________________________________________________ (Name) (Address) ______ Public School________________________________________________________________ (Town) (Address)

**** Indicate authorization by initialing below****

______ CAI Head Start/EHS ______ WIC

______ Early Intervention ______ Healthy Families

______ DCF ______ DTA

______ Child Care Circuit ______ Mass Health ______ North Shore Children’s Hospital

______ Boston Children’s Hospital

______CAI EHS/HS Mental Health consultants

______ Mental Heath Agency: (which one) ____________________________________________ Other: _________________________________________________________________________ *This release is valid for one year and can be rescinded at any time by the parent or guardian.

COMMUNITY ACTION, INC. FAMILY DAY CARE

75 Elm Street HAVERHILL, MASSACHUSETTS 01830

(978) 373-1971 / FAX (978) 521-1665

K.Cote 3/2019

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Other Explain__________________________________________________________________________








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Please Explain____________________________________________________________________________




Child’s Name _________________________________

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COMMUNITY ACTION, INC. FAMILY DAY CARE

ENROLLMENT PACKET F A C E S H E E T

Please fill out these forms completely. If a question does not apply to your child, write N/A (not applicable). The forms must be in the Educator’s possession on or before the first day your child begins care. Please notify your Educator if any of the information changes.

General Information

Today’s Date: ____________________ Start Date:______________ Age at Start Date: ______________

Date of Termination: __________Reason for Termination: _____________________________________

Child's full name __________________________________________________DOB ________________ *First *Middle * Last

Address:_______________________________ City:___________________ Zip:________________

Nickname: ______________________________ Place/City of Birth_____________________________

Primary Language of Child _________________ Primary Language of Parents_____________________

Parent/Guardian #1_____________________________________________________________DOB____________ *First *Middle * Last

Home address (if different) _______________________________________________________________________

Telephone Number:___________________________Email Address: _____________________________________

Location during child care hours: Where_________________________________Telephone___________________

Parent/Guardian #2_____________________________________________________________DOB____________ *First *Middle * Last

Home address (if different) _______________________________________________________________________

Telephone Number:___________________________Email Address: _____________________________________

Location during child care hours: Where_________________________________Telephone___________________

Are parents/guardians working the same time _______Yes _______No

Please check those that apply

□Single □Married □Divorced □Separated □Widowed □Sole Custody □Joint Custody □Temporary Custody

□Probate Custody □DCF Custody □Foster Placement Number of Hours Foster Parent Works Weekly ____________

Restraining Order Date_____________________ Date Vacated________________________

If you are in possession of a restraining order or custody permit, you must forward a copy to your FDC office and to the child care educator.

FDC Worker___________________________________________ DCF Worker________________________________________________

Child’s Name _________________________________

*P H O T O OF C H I L D(*Optional)

P L U SP H Y S I C A L

D E S C R I P T I O N

Eye Color _______ Hair Color ______ Sex_____ Height _____ Weight _______ Other:______________________________________________________________________

Children’s Records must be maintained for at least five (5) years after a child has left the program

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Child’s Name _________________________________

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TRANSPORTATION PLAN / AUTHORIZED PICK- UP

My child will arrive to the childcare home by: My child will depart the childcare home by: __Parent Drop-Off __Supervised Walk __Unsupervised Walk (School-aged children only with

signed permission form) __Public/Private Van __CAI FDC Van __Private Transportation Provided by Parent

__Parent Pick Up __Supervised Walk __Unsupervised Walk (School-aged children only with

signed permission form) __Public/Private Van __CAI FDC Van __Private Transportation Provided by Parent

In the space below, please note any important information regarding transportation of your child to and from the childcare home (i.e.--indicate who will be supervising children during transport or prior to their arrival at the childcare home, who supervises the walk to/from school bus stop, etc.) ____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Emergency Contact/Authorized pick-up person In the event of an emergency when I can not be reached, the educator or FDC staff may contact the following individuals (in the order given) who I also authorize to take my child from the child care premises.

(1) Name: _______________________________ Address _____________________________________

Telephone ________________________________Cell Phone _________________________________

Relationship to Child_________________________________________________

(2) Name: ______________________________ Address ______________________________________

Telephone _______________________________ Cell Phone __________________________________

Relationship to Child__________________________________________________

Please let your FDC family child care educator know at the beginning of the day when your child will be picked up by one of the authorized individuals.

Anticipated Days/Time of Attendance

Day Arrival Time Departure Time Day Arrival Time Departure Time

Monday ____________ ____________ Friday ___________ ____________

Tuesday ____________ ____________ Saturday __________ ____________

Wednesday ____________ ____________ Sunday ___________ ____________

Thursday ____________ ____________

If applicable: Name of School Child Attends: _______________________________________________

Child’s Name _________________________________

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Please Explain____________________________________________________________________________




Child’s Name _________________________________ P a g e | 3

Written Acknowledgement of Receipt of Parent Handbook

I acknowledge that I have received a copy of the Community Action, Inc, FDC Parent Handbook as well as information regarding lead poisoning prevention (may be included in the Parent Handbook).

_______________________________________________ ______________ Parent/Guardian Date

Parental Visit Notice

I understand that I may visit this family child care home unannounced at any time during the hours that my child is in care.

______________________________________________ _______________ Parent/Guardian Date

Photographs

Occasionally the Family Day Care staff photographs the children for parent meetings or at special events. I give my permission to the Family Day Care staff and the FDC family child care educator to photograph my child while in child care and at special events.

_______________________________________________ _______________ Parent/Guardian Date

Child's Physician or Health Care Professional

Name: ______________________________________________ Telephone: ___________________

Address: ___________________________________________

Information on allergies, special diets, chronic health conditions, special limitations, concerns including medications child is taking at home/school and possible side effects: ________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________

The “Individual Health Care Plan” (IHCP) or “At Home Medication” form may need to be completed

SCHOOL AGE ONLY

Current School: ____________________________ School Address: _________________________

______________________________________

I certify that documentation of physical examination and immunizations in accordance with public school health requirements, and lead poisoning screening in accordance with public health requirements are on file at my child’s school.

Parent/Guardian initials: ________________

Child’s Name _________________________________

PP aarr eenn ttaa ll SSii ggnn aatt uurr eess

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Other Explain__________________________________________________________________________








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Please Explain____________________________________________________________________________




Child’s Name _________________________________ P a g e | 4

DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION

Regulations for licensed child care programs require this information to be on file to address the needs of children while in care.

CHILD'S NAME _______________________________________ DATE OF BIRTH _____________

DEVELOPMENTAL HISTORY

Age began sitting ________ crawling ______ walking _________ talking ____________

Does your child pull up? Yes No Crawl? Yes No Walk with support? Yes No

Any speech difficulties? Yes No Please Explain_________________________________________

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: (Please indicate specific instructions regarding your child’s allergies)

________________________________________________________________________________________

Symptoms of child’s allergies:______________________________________________________________

Regular medications for allergies: ___________________________________________________________

EATING HABITS

Infant Eating Habits Parents must supply formula unless other arrangements have been made with the FDC family child care educator.

Breast Milk Yes No Formula Type_________________________________________________

Child’s Name _________________________________

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Other Explain__________________________________________________________________________








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Please Explain____________________________________________________________________________




Child’s Name _________________________________

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Does your child eat with spoon? Yes No Fork? Yes No Hands? Yes No

TOILET HABITS Is your child toilet trained? Yes No Schedule________________________________________________

Has toilet training been attempted? Yes No

Please describe any recurring problems with toileting or diapering______________________________________

__________________________________________________________________________________________

Is there a frequent occurrence of diaper rash? Yes No

Do you use: Baby Oil ________ Powder ______________ Lotion ________________ Other _____________

See page 7 (Permissions, Topical Medication/Ointments) for the above

Child’s Name _________________________________

EATING HABITS CONT.

If infant is on a special formula, describe its preparation in detail ____________________________________

_______________________________________________________________________________________

Feeding Times_________________________________________________Amount_____________________

Solid Foods______________________________________Cereal (brand)_____________________________

Baby Food (brand)__________________Fruit (type)________________Vegetable (type)_________________

Is your child fed held in lap? Yes No High chair? Yes No

Toddler Eating Habits

Favorite Foods: ___________________________________________________________________________

Foods refused: ____________________________________________________________________________

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Other Explain__________________________________________________________________________








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Please Explain____________________________________________________________________________




Child’s Name _________________________________

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Other Explain__________________________________________________________________________








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Please Explain____________________________________________________________________________




Child’s Name _________________________________

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Child’s Name _________________________________

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Permissions (for each child enrolled)

General Permission-(Basic Transport)Community Action, Inc, FDC Family Child Care Educator will provide each parent/guardian a specific permission form to be reviewed and signed giving consent to allow your child to be taken off daycare premises

Permission - (Transport to Medical Facility and Receive Emergency Medical Treatment)Medical Emergency Treatment (Department of Early Education and Care recommends checking with your local hospital about the acceptability of this statement)

I, hereby give __________________________________ permission to administer basic first aid and/or (Educator/Assistant or CAI, FDC staff)

CPR to my child ______________________________, and/or take my child to a hospital for medical

treatment when I cannot be reached or when delay would be dangerous to my child's health.

In addition, any or all of the following steps will be enacted: Attempt to contact you directly Attempt to contact you through those individuals listed as emergency contacts Attempt to contact your child’s physician

If we cannot contact you or your child’s physician we will do any of the following: Call an ambulance

Call another physician Have the child taken to an emergency hospital in the company of a staff person, when possible

Any liability incurred which is not covered by Community Action, Inc’s insurance policy will be borne by my family. In the event of illness, I give permission to Community Action, Inc’s staff to transport my child home if I am unable to do so. The program is not responsible for anything that may happen as a result of false information given at the time of enrollment. __________________________________ _____________________________________ Parent/Guardian Signature Date

Topical Medication/Ointments (Please list only those medications/ointments which you will allow the educator(s) to administer to your child's skin): Ex: sunscreen, insect repellent (bug spray), diapering ointment. (Not to include any prescription medication) ____________________________________________________________________________________

____________________________________________________________________________________

____________________________________ _____________________________________ Parent/Guardian Signature Date

Child’s Name _________________________________

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Other Explain__________________________________________________________________________








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Please Explain____________________________________________________________________________




Child’s Name _________________________________

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Emergency Card Information

REMINDER : This emergency card information is for the Educator’s first aid kit. The Educator(s) must take first aid materials when leaving the child care premises.

Child's Name:____________________________ Date of Birth:__________________________________

Child's Home Address:_________________________________________________________________

_________________________________________ Phone: ____________________________________

Instructions to Reach Parent or Guardian 1.__________________________________________________________________________________

(Name, Address, Home and Cell Phone #)

2.__________________________________________________________________________________ (Name, Address, Home and Cell Phone #)

Contact Information for Physician or Health Care Professional 1. _________________________________________________________________________________

(Physician’s Name, Address, Phone #)

Emergency Contact Person(s) 1. _________________________________________________________________________________

(Name, Address, Home and Cell Phone #)

2. _________________________________________________________________________________(Name, Address, Home and Cell Phone #)

Emergency Medical Treatment

I hereby give ____________________________________________________________ permission to (Name of Educator/Assistant)

administer basic first aid and/or CPR to my child _____________________________________________ (Name)

and/or take my child _______________________________________, to a hospital for medical treatment (Name)

when I cannot be reached or when delay would be dangerous to my child's health.

_______________________________________ ______________________________________ Parent/Guardian Date

Medical Insurance Information (Optional)

Subscriber's Name:____________________________________________________________________ Type of Insurance:_____________________________________________________________________ Policy Number:_______________________________________________________________________ [ ] Copy of insurance card Other pertinent medical information:_______________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Child’s Name _________________________________

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Child’s Name _________________________________ P a g e | 9

Community Action, Inc Family Day Care

75 Elm Street Haverhill, MA 01830

Parent Agreement

I, ____________________________________________________________ agree that my Parent/Guardian

child______________________________________________________________________

will be brought to the Family Day Care home at:

_________________________and will be picked up at_________________________ Time Time

HoursIn case my child cannot be brought or picked up according to the above schedule, I will telephone in advance to let the FDC Educator know. If my hours need to be changed, I will complete a revised parent agreement. If my FDC Educator cannot accommodate my new hours, I may choose to give a two-week notice for another placement.

If a change in the person picking up my child is to be made, I will notify the FDC Educator in advance. I agree to inform the FDC Educator where I can be reached while my child is in care, so that I may be contacted in an emergency.

ClothingI will be sure that my child is properly dressed for outdoor activity appropriate to the weather. I will also leave a change of clothing with the FDC Educator in case a change is needed. I will provide an adequate supply of diapers each day.

HealthI will provide the Family Day Care office with my child’s immunization record before my child is enrolled. I will also submit documentation of a completed physical within 30 days of enrollment.

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Child’s Name _________________________________ P a g e | 10

Health Cont.

I agree that my child cannot go and or stay in child care if he/she is sick with a fever of 100-101 degrees, is vomiting or has diarrhea. I agree to pick up my child if he/she becomes ill while in child care.

Before asking the FDC Educator to give medication, I will submit a completed “Authorization to Administer Medication” form signed by me. This form is available at the FDC office or from the FDC Educator.

All prescription medications must be brought to the FDC Educator’s home by the parent/guardian in the original container.

If my child requires long term medication he/she will receive the dosage at home whenever possible. I will submit a completed “At Home Medication” form. The “At Home Medication” form must also be completed if my child has been given any medications at home. This form is available at the FDC office.

If my child has been diagnosed with a chronic medical condition, I will furnish the required “Individual Health Care Plan” (I.H.C.P), prior to enrollment, which has been completed and signed by my child’s physician.

I further agree that I will meet the FDC Educator and my child at the hospital if medical care is necessary.

I understand that all FDC Educators and Community Action, Inc. staff are mandated reporters. FDC Educators shall report all incidents regarding my child to the FDC Director, FDC Assistant Director or appropriate Case Worker. I agree to notify the FDC Educator, in verbal or written form of any cuts, bruises or scrapes on my child.

I have read and understand this form fully before signing it.

________________________________________________ _________________ Parent Signature Date

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Other Explain__________________________________________________________________________








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Child’s Name _________________________________

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Community Action, Inc Family Day Care

75 Elm Street Haverhill, MA 01830

Parental Consent Form

Supervision While Accompanying A Child To And From A Vehicle

At times, it is required of your Family Day Care Educator to accompany a child to and from a specialized transportation vehicle. When this occurs, your child may be left briefly in the family childcare home unsupervised. Family child care licensing regulations require that the caregiver exercise good judgment in supervising children who are in his or her care. Please sign the following consent:

I__________________________________have read and understand the Commonwealth of Parent/Guardian

Massachusetts “Notice to Parent Regarding Supervision of Children Involving Transportation” which is included in the FDC Parent Handbook. I understand that my Family Day Care Educator:

_____________________________________________________________________________Educator Name

May be leaving my child/ren:

_____________________________________________________________________________

alone while she/he brings another child to/from the vehicle and that she/he will take all the required steps to ensure my child’s safety.

_____________________________________________ _________________ Parent/Guardian Signature Date

9/2011 KC

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Child’s Name _________________________________

THE DEPARTMENT OF EARLY EDUCATION AND CARE SUBSIDIZED CHILD CARE

ATTENDANCE NOTIFICATION AGREEMENT

Effective Date: March 1, 2019 (revised March 18, 2019)

Your child(ren) are receiving an EEC child care subsidy and are expected to attend the early education and care program, as agreed on your child care authorization. Your provider is responsible to make sure that your child(ren) attends based on the agreed schedule. EEC defines Excessive Absences as more than 45 non-attended days, including any unexplained absences, within a 12 month Authorization period, or more than 15 non-attended days during an initial 12-week Provisional Authorization period. Parent(s) will have to pay for all non-attended days over the 45 day limit during a 12 month authorization or all non-attended days over the 15 day limit during a 12-week Provisional Authorization. To help avoid having to pay for Excessive Absences you must:

1. Make sure that your child(ren) attend(s) the early education and care program; 2. Notify your Subsidy Administrator of any changes in your child(ren)’s schedule of care (i.e. after school

programs, sports, custody arrangements) which will result in your child(ren) not needing child care on a particular day or days of the week;

3. Provide at least 2 weeks advance written notice if you plan to remove your child(ren) from the child care program; and

4. Request an Approved Break in Care for absences that are going to be longer than 2 weeks.

You will receive notices from your Subsidy Administrator after your child(ren) have reached 30 absences and 40 absences. If you have a 12-week Provisional Authorization, you will be notified after your child(ren) have reached 10 absences. The purpose of these notices are to inform you when your child(ren) are approaching the Excessive Absence limit so that you can be aware of the impact of future absences. After your child(ren) have reached their 45th absence, or the 15th absence during a 12-week Provisional Authorization period, you will be notified that your child(ren) have reached the Excessive Absence limit and that you are now responsible for the payment of all additional absences during the authorization period at the full rate that EEC pays for your child care. You will be asked to sign the Excessive Absence Warning Notice form confirming that you are willing to remain in care and will be responsible for the payment of all absences during the remainder of the authorization period. Please note that failure to sign the form will not excuse you from paying for additional non-attended days. Failure to pay for additional absences may result in the termination of your subsidized child care. EEC defines Excessive Unexplained Absences as failure to attend a subsidized child care program for more than three consecutive Days without contacting the provider. The first time your child is absent more than 3 days in a row during a 12 month Authorization, your provider or the Subsidy Administrator will issue you an Excessive Unexplained Absence Warning Notice that any additional instances of Excessive Unexplained Absences may result in the termination of child care. To avoid having unexplained absences, you must make sure to contact your provider every day that your child(ren) will not attend. My signature below indicates that I understand the information in this document and agree to comply with the requirements above. ___________________________________________________ _____________________________________ Printed Name of Parent Date _____________________________________________________________________________________________ Signature of Parent

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Child’s Name _________________________________ P a g e | 16

Child Support Services Are Available

During intake, Community Action staff is required to inform all custodial parents in single‐parent families of the availability of child support services.

In Massachusetts, child support services are part of the Massachusetts Dept. of Revenue (DOR) in the Child Support Enforcement Division.

Their toll‐free nationwide number is ...... 1‐800‐332‐2733. This is for general information about child support enforcement in Massachusetts and for any type of assistance regarding your case.

DOR provides child support collection services to all "custodial parents" (parents who have physical custody of their children) in the state of Massachusetts. Some people think DOR gives priority to getting child support orders for women on TAFDC (formerly AFDC or welfare). DOR tries to make sure that parents pay back the Commonwealth of Massachusetts for supporting children on TAFDC. When you apply for DOR services, you give them the ability to establish and collect child support on your behalf. To apply for DOR services, you can get an application from your intake worker here at Community Action, from your local Probate and Family Court,* or online at http://www.mass.gov/Ador/docs/cse/service/BrochureApplication.pdf You can also apply online at https://ecse.cse.state.ma.us/ECSE/home/requestservicesapp/index.asp

Child Support Enforcement info including an introductory video, the online application and tutorials for how to use their “Case Manager” online tools can be found on the Mass. Dept. of Revenue’s website at www.mass.gov/cse

Excellent resources are also posted at: http://www.lawlib.state.ma.us/subject/about/support.html and at http://www.masslegalhelp.org/children‐and‐families/child‐support (in several languages)

Whichever way you choose, if you fill out the application and send it in, DOR does not charge a fee for this service. When filling in the application make sure you check “yes” if you want services and pick the service(s) you want them to provide. Here you should think about the services that you may require in the future as well as currently.

When children receive public assistance ("welfare" or "TAFDC"), the state collects the child support from the non‐custodial parent. The state sends $50 per month of the child support to the parent and child(ren) who are receiving public assistance. The rest of the child support goes to repay the state for the cost of public assistance.

If you are worried about domestic violence in relation to child support, another good resource is: http://www.masslegalhelp.org/domestic‐violence/chapter2‐making‐it

* Essex Probate and Family Court is in both Salem (call 978-744-1020 x380 ) and Lawrence(call 978-686-9692).

I have received a copy of this information sheet which is included in the FDC Parent Handbook.

________________________________________________ _____________________ Signature Date

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Child’s Name _________________________________

Signed Original placed in Child’s Folder

3/2019 KC

Community Action, Inc

Family Day Care &

Head Start / Early Head Start

Policy and Procedures

For Payments/Late Payments

Community Action, Inc. is responsible for the collection of parent fees. Your weekly parent fee is due on Friday before each week of care and no later than the first business day of the week in which care is provided. Upon enrollment, an initial deposit plus the first week payment both equal to the amount of the weekly parent fee is required prior to the child’s first day of care. You should be prepared to make a minimum payment equal to 2 weeks of your assessed fee. This will cover your first week of care and the deposit to be held for the last week your child attends care. In the event you leave the program, the one week deposit will be applied against the last week of childcare. Any balance remaining will be returned to you. Parent billing statements are mailed monthly to the most current address we have on record. Although your statement is mailed out monthly, you are required to pay your fee weekly as stated above. In the event that your parent fee falls behind, you will be issued a Non-Payment of Parent Fees Warning Notice. If you fail to respond to the Non-Payment of Parent Fees Warning Notice, including paying the balance prior to the next Parent Fee Due date and maintaining subsequent week’s Parent Fees, you will be issued a 2-week Notice of Termination. Your program and/or educator will be notified of this termination and cannot take your child into care after that date. Community Action, Inc child care programs encourage communication between you and our Fiscal Department if you encounter a financial hardship in any given week. We encourage you to call your program department for further clarification if needed. Your signature below states that you have received and understand our Payment and Late Payment Policy. Parent Signature: _________________________________Date:________________ Staff Signature: __________________________________Date:_________________ Signed Original placed in Child’s Folder

3/2019 KC

Community Action, Inc

Family Day Care &

Head Start / Early Head Start

Policy and Procedures

For Payments/Late Payments

Community Action, Inc. is responsible for the collection of parent fees. Your weekly parent fee is due on Friday before each week of care and no later than the first business day of the week in which care is provided. Upon enrollment, an initial deposit plus the first week payment both equal to the amount of the weekly parent fee is required prior to the child’s first day of care. You should be prepared to make a minimum payment equal to 2 weeks of your assessed fee. This will cover your first week of care and the deposit to be held for the last week your child attends care. In the event you leave the program, the one week deposit will be applied against the last week of childcare. Any balance remaining will be returned to you. Parent billing statements are mailed monthly to the most current address we have on record. Although your statement is mailed out monthly, you are required to pay your fee weekly as stated above. In the event that your parent fee falls behind, you will be issued a Non-Payment of Parent Fees Warning Notice. If you fail to respond to the Non-Payment of Parent Fees Warning Notice, including paying the balance prior to the next Parent Fee Due date and maintaining subsequent week’s Parent Fees, you will be issued a 2-week Notice of Termination. Your program and/or educator will be notified of this termination and cannot take your child into care after that date. Community Action, Inc child care programs encourage communication between you and our Fiscal Department if you encounter a financial hardship in any given week. We encourage you to call your program department for further clarification if needed. Your signature below states that you have received and understand our Payment and Late Payment Policy. Parent Signature: _________________________________Date:________________ Staff Signature: __________________________________Date:_________________

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Child’s Name _________________________________


PARENT INFORMATION SHEET

Effective Date: March 1, 2019

The Department of Early Education and Care (EEC) provides funding for early education and care for your child (ren). This financial assistance, also known as a subsidy or as subsidized child care, enables your child(ren) to attend quality early education and care programs at a reduced rate. We want to work with you to maintain your eligibility for subsidized care so we have put together this check list to assist you in keeping this benefit.

HOW YOU CAN MAINTAIN YOUR EARLY EDUCATION AND CHILD CARE SUBSIDY:

• You must maintain a “service need” for a minimum number of hours. EEC defines “service need” as employment or enrollment in an education or training program:

o If you have 20 hours of a service need, you are eligible for part-time child care (up to 30 hours of care each week) o If you have 30 hours of a service need, you are eligible for full-time child care (up to 50 hours of care each week) o You may combine work and education/training to meet the minimum number of hours.

• Your child(ren) must attend his/her early education and care program as authorized by your Subsidy Administrator • You must maintain open communication at all times with your Subsidy Administrator listed below regarding any changes

that might affect your eligibility. Temporary and Non-temporary changes must be reported immediately, but no later than 30 days after the change. Temporary changes include changes to your situation such as:

o Any time-limited absence from your service need due to an illness or need to care for a family member (includes maternity/paternity leave);

o Any interruption in work for a seasonal worker who is between regular work seasons; o Any reduction in your service need hours, as long as you are still working or attending education/training; o Any other break in your service need that does not exceed 12 weeks; and o Any change in residency within Massachusetts.

Non-temporary changes include changes to your situation such as: o Increases in your total household income that exceed 85% of State Median Income (SMI); o Changes in your household’s composition (who lives with you) for more than 30 total days during your 12 month

authorization; o Changes in your child(ren)’s custody arrangements; o Any out of state change in address; o Any change or break in your service need that lasts more than 12 weeks.

• You must maintain accurate contact information with your Subsidy Administrator (Phone, address, and e-mail address). • You must pay all assigned parent fees on time. • You must submit all required documents to complete your Reauthorization prior to the end date of your current

authorization to continue subsidized child care if you are eligible. • You must comply with all Regulations and Policies as required by EEC, your Subsidy Administrator, and your Provider.

POTENTIAL CAUSES OF TERMINATION OR DENIAL OF SUBSIDIZED EARLY EDUCATION AND CARE

• Failing to report a non-temporary change, failing to accurately report income, failing to respond to an EEC request, or Non-Payment or late payment of your assigned parent fee (this is called “Intentional Program Violation ”)

• Providing false or misleading information about your household size, income, family composition, or service need (this is called “Substantiated Fraud”)

• If you engage in Substantiated Fraud or have an Intentional Program Violation, your subsidized child care may be terminated but you also may receive sanctions that will prevent you from accessing subsidized child care for a period of time. You may also be required to repay the cost of child care, and/or you may be assessed a criminal/civil fine.

• Sanction (period of time when you are not allowed to have subsidized child care) that has been issued to you by EEC • Not having a service need of work or education/training • Failure to meet financial eligibility, including being over income or having too many assets (vehicles, cash, houses, etc.) • Failure to submit required documentation on time • Failure to maintain your residence within Massachusetts • Your child’s lack of attendance on authorized days without notice to the program (Excessive Unexplained Absences) • Abandonment of Subsidy (not having a placement for your child for more than 30 days unless you have an Approved Break

in Care) • Failure to comply with EEC, Subsidy Administrator, or Provider policies may result in termination of care at a particular

program, but not the loss of your subsidized child care.

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Other Explain__________________________________________________________________________








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Please Explain____________________________________________________________________________




Child’s Name _________________________________


PARENT INFORMATION SHEET


IMPORTANT INFORMATION TO KEEP IN YOUR SUBSIDIZED CHILD CARE HOME FILE

When you leave your appointment today you will receive a copy of the following documents:

• Voucher (if applicable) - this form includes the following information: the period of time you are authorized for; where your child(ren) are authorized to attend; your parent fee (if applicable)

• Application and Fee Agreement – this form includes the following information: all members of your household; all household income; where your child(ren) are authorized to attend; your parent fee (if applicable)

• Financial Assistance Agreement – this form explains your rights and obligations for EEC subsidized child care • Household Income Statement – this form confirms the income information that you have reported to your Subsidy

Administrator • Household Composition Statement - this form confirms the members of your household that you have reported to your

Subsidy Administrator • Attendance Notification Agreement – this form explains EEC’s attendance policies and what your responsibility is if your

child will not attend on any given day he/she is authorized to attend • SMI Calculation Sheet – this form provides what 85% of the State Median Income (SMI) would be for your household size

and provides instructions on how to calculate your new SMI if you have an increase in income

At least 45 days prior to the end of your subsidy, a reminder notice will be sent to you so that you may confirm your ongoing eligibility for subsidized child care and complete your Reauthorization. To help you, we have scheduled your next appointment and it is included with the information below. If you must change your appointment date and/or time, please ensure that you schedule your appointment and complete your Reauthorization no later than _____ days before the end date of your current Authorization. Please be sure to place this in your personal file and mark it on your calendar.

________________________________________________________________________________________________________

PARENT SIGNATURE DATE

IMPORTANT INFORMATION:

Your Current Authorization Expires On: __________________________ Your Next Appointment is On: ______________________

Your FID# (Family Identification Number): _________________________________________________________________________

Your Subsidy Administrator’s Agency is: __________________________________________________________________________

Your Subsidy Administrator’s Name is: ____________________________________________________________________________

Your Subsidy Administrator’s number is: __________________________________________________________________________

Your Subsidy Administrator’s Fax is: ______________________________________________________________________________

Your Subsidy Administrator’s E-mail is: ___________________________________________________________________________

If you have any questions about these policies, please contact your Subsidy Administrator listed above.

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Other Explain__________________________________________________________________________








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Please Explain____________________________________________________________________________




Child’s Name _________________________________


PARENT CONTACT INFORMATION FORM


The Department of Early Education and Care (EEC) requires that families maintain updated contact information, which includes: physical address, mailing address, phone number(s), and e-mail addresses. If your contact information changes during your Authorization period, you must submit a copy of this form to your Subsidy Administrator. These changes are expected to be reported immediately, but no later than 30 days from the date of the change. All correspondence will be sent to the address on file. If we do not have a current and accurate address, it may impact our ability to reach you with important notices in a timely manner. Documentation of the change (such as proof of address) does not need to be submitted until your next Reauthorization. Please complete the entire form. Please check appropriate box:

Initial Change/Update

Physical Address: _________________________________________________________________

_________________________________________________________________

Mailing Address: _________________________________________________________________

_________________________________________________________________

Home Number: _________________________________________________________________

Work Number: _________________________________________________________________

Mobile Number: _________________________________________________________________

E-Mail Address: _________________________________________________________________

EEC encourages the use of technology to notify Parents of any changes to your subsidy or to advise that it is time to have your subsidy Reauthorized. Please indicate below if you are requesting to receive your notifications via e-mail.

Notifications via e-mail is offered by this Subsidy Administrator: Yes No

Yes, I would like to receive notifications via e-mail

No, I would like to receive notifications via U.S. mail

Signature of Parent: ____________________________________________ Date: ___________________ Print Parent Name: _______________________________________________________________________ Subsidy Administrator Agency Name: ________________________________________________________ Subsidy Administrator Staff Member: ________________________________________________________ Received on: __________________________ DATE

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Other Explain__________________________________________________________________________








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Please Explain____________________________________________________________________________




Child’s Name _________________________________


HOUSEHOLD COMPOSITION STATEMENT


Please read carefully and mark “X” to all that apply.

I certify under penalty of perjury that the information below is correct and complete to the best of my knowledge. I understand that I must report any changes in countable household members that last more than 30 total days during a 12 month Authorization. Providing inaccurate details about my household composition will lead to the conclusion that I provided false and misleading information. I understand that providing false or misleading information to my child care Subsidy Administrator and the Massachusetts Department of Early Education and Care (EEC) may result in the immediate termination of my child care subsidy. I also understand that EEC may require that I repay any improper payments for child care financial assistance that I received after I provided false or misleading information.

CHECK ALL THAT APPLY:

I AM LEGALLY MARRIED o Spouse’s Name and Date of Birth - ___________________________________________________

I AM LIVING WITH THE FATHER/MOTHER OF MY CHILD(REN) o Father/Mother’s Name and Date of Birth - _____________________________________________

I AM LEGALLY DIVORCED I AM WIDOWED I AM LEGALLY SEPARATED FROM MY LEGAL SPOUSE

o Spouse’s Name and Date of Birth - ___________________________________________________ I AM INFORMALLY SEPARATED FROM MY LEGAL SPOUSE

o Spouse’s Name and Date of Birth - ___________________________________________________ I DO NOT LIVE WITH THE FATHER/MOTHER OF MY CHILD(REN)

PLEASE LIST THE NAME OF EACH MEMBER OF YOUR HOUSEHOLD AND INCLUDE HIS/HER FULL NAME, DATE OF BIRTH AND RELATIONSHIP:

FULL NAME DATE OF BIRTH RELATIONSHIP TO THE PARENT

___________________________________________________________ ________________________________

Print Parent Name Social Security Number ____________________________________________________________ ________________________________

Signature Date

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Other Explain__________________________________________________________________________








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Child’s Name _________________________________


FINANCIAL ASSISTANCE AGREEMENT


This document explains your rights and your obligations regarding EEC child care financial assistance. Please read this document carefully and ask for clarification if you do not understand any part of it. You should keep a copy for your files.

Parent's Initials:

_______ I understand that it is unlawful to obtain EEC financial assistance for child care services by providing false or misleading information or documentation, or the concealing or withholding of information (“Substantiated Fraud”), for the purpose of establishing or maintaining eligibility or increasing the level of child care assistance.

• Some examples of such unlawful behavior include, but are not limited to: o Not reporting who is in my household (for example, not reporting that I am married or the child's other parent

lives with me); o Not reporting all sources of my income (for example, not reporting that I receive income from another source

including but not limited to: additional employment, rental income, child support payments, alimony, or financial help from another parent to assist with my child's basic needs);

o Not accurately reporting how much income I receive (for example, not reporting all money received from self-employment, or altering or falsifying pay stubs);

o Not accurately reporting my service need (a service need is the activity - work, education, or training - performed during the time you need child care) or changes to my service need.

________ I understand that providing false or misleading information or documentation, or the concealing or withholding of information (“Substantiated Fraud”), when applying for EEC financial assistance may result in the termination of my child care financial assistance. ________ I understand that I must report Temporary and Non-Temporary Changes within thirty (30) days from the date the change occurred. Temporary Changes include: time limited absence from a service need due to illness or need to care for a family member (including maternity/paternity leave), interruption in work for a seasonal worker, reduction in service need hours, change or cessation of a parent’s service need that lasts less than 12 weeks; and a change of residency within the Commonwealth. Non-temporary Changes include: increases in total household income exceeding 85% of State Median Income (SMI); changes in family contact information; changes in household composition; changes in child custody arrangements; any out of state change in address; or any change or cessation of a parent’s service need that lasts more than 12 weeks. I understand that failure to report Non-Temporary Changes will result in an Intentional Program Violation (IPV) and may make me subject to disqualification from EEC financial assistance ________ I understand that if I receive EEC financial assistance as a result of false or misleading information or documentation, or as a result of the concealing or withholding of information (“Substantiated Fraud”), I shall be responsible for repayment of the full amount of subsidy obtained through fraud and may be held criminally responsible. ________ I understand that to verify my income and service need, EEC or the Subsidy Administrator may need to contact my employer(s), college/university, school, or training program. I hereby authorize my employer(s) or school administration to release information about my income, pay, hours, schedule of work, and school enrollment information to EEC or the Subsidy Administrator to whom I apply for subsidized child care services. ________ I agree to pay all weekly fees to the authorized child care provider. I understand I am responsible to pay an initial deposit of 1 week plus the cost of the first week of care prior to the start of the subsidy. I certify under the pains and penalties of perjury that the information provided is correct and complete to the best of my knowledge. Parent Name____________________________________________________ SSN ________________________________

Address _____________________________________________________________ _______________________________________

Parent Signature_________________________________________________ Date _______________________________

Subsidy Administrator Staff Member Name ________________________Subsidy Administrator Agency Name ________ __________

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_______________________________________________________________________________________




____________________________________________________________________________________________



Other Explain__________________________________________________________________________








________________________________________________________________________________________


Please Explain____________________________________________________________________________




Child’s Name _________________________________


HOUSEHOLD INCOME STATEMENT


Please read carefully and mark “X” to all that apply. You may be asked to provide documentation of income.

I certify under penalty of perjury that the information below is correct and complete to the best of my knowledge. Providing inaccurate details about my household income will lead to the conclusion that I provided false or misleading information. I understand that providing false or misleading information to my child care Subsidy Administrator and the Massachusetts Department of Early Education and Care (EEC) may result in the immediate termination of my child care subsidy. I also understand that EEC may require that I repay any improper payments for child care financial assistance that I received after I provided false or misleading information. I AM CURRENTLY RECEIVING (COMPLETE ALL THAT APPLY - DO NOT LEAVE LINES BLANK, PUT A ZERO IN IF IT DOES NOT APPLY):

Type of Income Parent #1 Amount

Parent #1 Frequency (Monthly, Weekly, etc)

Parent #2 Amount

Parent #2 Frequency (Monthly, Weekly, etc)

Earnings from Employment $ ________ _________ $ ________ _________ Tips Earned $ ________ _________ $ ________ _________ Business Income $ ________ _________ $ ________ _________ Commission $ ________ _________ $ ________ _________ Child Support $ ________ _________ $ ________ _________ Alimony $ ________ _________ $ ________ _________ TAFDC (NOT SNAP Benefits) $ ________ _________ $ ________ _________ DTA Transitional Stipends $ ________ _________ $ ________ _________ Rental Income $ ________ _________ $ ________ _________ SSI / SSDI $ ________ _________ $ ________ _________ Unemployment Compensation $ ________ _________ $ ________ _________ Workers’ Compensation $ ________ _________ $ ________ _________ Veteran’s Benefits (i.e. retirement, disability, etc.) $ ________ _________ $ ________ _________ Dividends or Income from Trusts/Estates $ ________ _________ $ ________ _________ Other __________________________ $ ________ _________ $ ________ _________

I RECEIVE IN-KIND SUPPORT. In-kind support can include receiving money from the non-custodial parent for things like: diapers, food, gas, payment of a bill or mortgage, informal alimony, or other forms of support. In-Kind support does not include payments made through DOR or the Courts. The estimated value of this support is: $________________________________________ I receive this support (circle one): Annually Monthly Weekly Irregularly If You are NOT Receiving ANY Support:

I have a court order for child support, however, I am not receiving support at this time. I have a court order for alimony, however, I am not receiving support at this time. I am NOT receiving any alimony, spousal, child support or other compensation FROM ANY COURT ORDER OR OTHER AGREEMENT. I do not receive support from any source at this time, including in-kind support. _______ (Initial) I certify that my household does not have assets with a combined value of more than $1 million. Assets are valuables including, but not limited to, all houses or other buildings, real property, vehicles, cash, bank accounts, cash value of life insurance policies, trusts, stocks, bonds, and overall business value, including equipment, jewelry, livestock, or other goods.

____________________________________________________________ ________________________________

Print Parent Name Social Security Number ____________________________________________________________ ________________________________

Signature Date

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