2115 wardrobe ave. merced, ca 95341 · 2020-05-26 · 2115 wardrobe ave. merced, ca 95341 • _____...

209.722.2327 [email protected]

2115 Wardrobe Ave. Merced, CA 95341

On behalf of Bear Country, I would like to welcome you to our Preschool and Afterschool Program. Services are provided Monday through Friday and are open from 6:30 a.m. to 6:30 p.m. I provide an atmosphere of trust. I want you to have complete peace of mind that while with us your child will be safe. My staff offers engaging learning experiences that are developmentally appropriate and will prepare your child for elementary school. If you have any questions or concerns, please do not hesitate to call me at (209) 722- 2327. I encourage you to be an active partner with us in the education of your child. Sincerely,

Regina Wolf Regina Wolf Program Director

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My child(ren) _____________________________________________________

will attend Bear Country Preschool & Afterschool Program on the following days:

M T W T F

From _______ AM/PM to _______ AM/PM and weekly tuition fee will be $________.

My school age child’s full-time weekly tuition school break fee will be $________.

• _______ I understand that Bear Country Preschool offers full time, part time, and before school and after school care. I understand that the rate from the rate sheet and understand the difference between full time, part time, and before and after school care. I also understand that it’s part time if its five hours or less, anything above five hours is full time.

• _______ I understand that I must sign my child in and out using the exact time as required by state licensing and that I will escort my child to his/her classroom.

• _______ I understand that an annual, non-refundable $100 shall be paid in advance to enroll my child and will be due every August to continue enrollment.

• _______ I understand that if I am on access or some other program for assistance, I am the person responsible for submitting all required documents to the agency and to Bear Country Preschool. I also understand that I am responsible for any payment or portion of payment not received from the agency.

• _______ I understand that Bear Country Preschool & Afterschool Program is open from 6:30 AM to 6:30 PM Monday through Friday, except for announce changes for holidays. I understand that if I fail to pick up my child by 6:30 PM, a late pick up fee of $15 for every 15 minutes I’m late will be applied per child. I also understand that if my child is scheduled for a half a day program and I pick him/her up after the five hours the late pick up fees may apply.

• _______ I understand that Bear Country Preschool & Afterschool Program only accepts payments in the form of a Check, Money or Cash. If my check is returned for any reason Bear Country Preschool & Afterschool Program will apply a return check fee of $35.00 in addition to any other fees my financial institution may charge me.

• _______ I understand that Bear Country Preschool will be closed on the following holidays: New Year’s Day, Martin Luther King Jr, Day, Memorial Day, Presidents Day, Independence Day, Labor Day, Thanksgiving Day and day after Thanksgiving, Christmas Eve, and Christmas Day. The observance of these holidays will be in accordance to industry standards. If the holiday falls on the Saturday, then we will take it on that Friday and if it falls on a Sunday then we will take it on Monday.

• _______ I understand that I will not receive credit, refunds, or remakes on days my child is absent from the center because of illness, holidays, or emergencies.

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• _______ I authorize Bear Country Preschool & Afterschool Program to use photographs, reproductions, of my child for advertising, publicity or any other lawful purpose.

• _______ I understand that if I photograph, videotape, or audio record my child on Bear Country Preschool and Afterschool Programs, I may only use such recordings. I also understand that I must have written permission before capturing any image of other children or staff other than my child.

• _______ I understand that child care regulatory enforcement and administration agency and the local department of social services or child protective services has the authority to interview children or staff, to inspect and audit child and facility records, to interview children privately, to observe the physical condition or the children in the center, and to contact and instruct any other appropriate authority to do the same, without prior notice or consent by myself or Bear Country Preschool & Afterschool Program.

• _______ I understand that Bear Country & Afterschool Program reserves the right at all times to refuse to provide or continue service at our state at our sole discretion and without cause.

• _______ I understand that the above policies are not an all-inclusive list of policies, and that my child, my family members, authorized agents, and I are bound by state child care regulations, the family handbook, and any other company policies, which may be modified at any time with proper notice. I also understand that I may change my child’s schedule based on our family’s needs, and our change or update any of the information provided and may need to fill out new enrollment documents.

• _______ I understand that I must receive a 30-day advance notice before any rate change. • _______ I understand if any legal actions are necessary to enforce the terms of this

agreement, the prevailing party shall be entitled to reasonable attorney’s fees in addition to any other relief to which they may be entitled.

• _______ I understand that I am required to give two weeks’ notice in writing of my intention to terminate my child’s enrollment or I will be charged for these two weeks regardless of attendance.

• _______ I understand if my child (ren) for Afterschool Pickup will not be needed for that day’s pickup, then you must call at least 2 hours in advance of scheduled pickup time.

Bear Country Preschool & Afterschool Program does not discriminate on the basis of:

Religion, color, race, gender, age, disability, or any other factors protected by law.

Parent/ Guardian Name: _______________________________________ Date: ________________

Parent/ Guardian Name: _______________________________________ Date: ________________

Email: ______________________________ Director Name: ___Regina Wolf___________________

Director Signature: __________________________________________ Date: __________________

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Bear Country Philosophy Our philosophy for children ages 2-12 is to build on their strengths and interest, to provide a clear guidance on the content in language, math, art, music, movement, history, science etc. We plan to a accomplish this through hands-on learning. Preschool Goals

To enhance the total growth of the child by providing activities that will: • Provide a wide range of experiences, which form a basis for future learning in

language, mathematics, science and music • Learn to handle his or her own emotions and consider the feelings of others • Help children learn to become independent and responsible • Encourage thinking skills and creativity • Opportunity for physical development • Develop problem solving skills • Communication Skills • Curiosity

About the Program

The preschool classes serve 24 children and is instructed by a teacher possessing at least a Childhood Development Permit in Early Childhood Education. A highly qualified instructional assistant works with the teacher. It is the responsibility of the teaching team to create a stimulating environment and to provide and guide the educational experiences of each child. Lunch and snacks are provided for the children. Most children require a certain amount of time to adjust to the preschool program. After this initial adjustment period, if the teacher has a concern about a child’s developmental progress, they may recommend a recommend a referral. The referral would be to a local agency designed to accommodate the child’s individual needs.

Learning Goals

• To make good decisions about their behaviors • To cooperate with other children and adults • To communicate with others about their experiences and feelings • To take initiative and solve problems • Reading and math skills and concepts

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Curriculum

The preschool faculty is trained in and uses Houghton Mifflin Program in conjunction with a reading readiness program called the Scholastic Early Childhood Learning Program that is a multisensory Pre-K curriculum. Our curriculum is a nationally validated program and it is used throughout various school districts. The daily schedule in the classroom is clearly defined for the preschoolers. The children learn when it’s time to work, cleanup time, circle time, small group and outside time. By calling each period of the day by name, children learn a sense of time and order. Children also learn to identify each area of the room (the art area, quiet area, housekeeping area and the block area) as well as where the materials belong because each area is labeled with pictures and words. This establishes in the child’s understanding a connection between the object, picture and word. This understanding is the foundation of reading readiness. In addition, the orderly environment promotes independents and initiative because children know where material are located.

Daily Lessons Focus On

• Language and literature • Numbers and classification • Space and time • Incentive and social relations • Creative representation • Music and movement

The teacher’s role is to prepare material that will provoke an understanding of the concepts and to interact with the children in ways that develop language and thinking.

The highlight of Houghton Mifflin curriculum is the cycle of “plan, do and review.” This is approximately an hour-long block of time when children choose areas of the room in which to work, implement their plans, and then review with other children what they have accomplished. During this work time the teachers observe children and record notes on the specified actions of individual children that relate to “key experiences.” Additionally, teachers help children to solve problems when they encounter them. Primary during circle time the teacher use the reading readiness program, Scholastic Early Childhood Learning Program. The components of the program are:

• Book-a-week • Alphabet-a-week • Take-home activities

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The children learn to identify letters and rhyming words and build comprehensive and beginning writing strategies. The take-home component of the program provides a supplied book and a related activity for parents and children together.

Field Trips

The preschool provides field trips on occasion to enrich your child’s learning and provide hands-on experiences in your community. A permission slip will be sent to you and must be filed at your child’s school prior to each field trip.

Parent Involvement The parent is a child’s first and most important teacher. As a child starts school, the need for consistency between the home and school is important. Therefore, the parent and teacher must work together to help the child feel secure. To that end, it is expected that the parents will participate in:

• Take-home activities with their child • Fall and Spring school conference on their child’s progress

Student Progress

Children are assessed in the fall and the spring of the preschool year to determine how far each child has progressed.

The Student Assessment Report is an individual administered assessment that measures:

• Oral Instructions • Phonological Awareness • Letter Knowledge • Beginning sounds of letters • Verbal Memory • Print Knowledge • Concept of word • Name Writing

The Child Observation Records are correlated with “key experience.” This method of assessment is based on teacher’s daily anecdotal notes of children’s behaviors. The teacher then classifies the notes for each child on a developmental scale for each of the following areas:

• Language and Literacy • Creative Representation • Music and Movement • Social Relations • Math and Logic

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Preschool Parent/ Teacher Conferences

Parent/teacher conferences will be twice per school year. Parents will be contacted to arrange the dates and times for he conferences. Scheduling will be conducted when it is convenient for both the parents and the teachers.

Attendance/ Absence Parents are responsible for their child’s regular attendance at school. The program expects your child to attend school unless he or she is ill. If your child will not be in attendance you must notify the school and give a reason or send a note with your child when he/she returns to school. According to the State Preschool Regulations, the following absences are considered excused:

• Illness or quarantine of the child o Family Emergency (death of an immediate family member)

Please let us know in advance of: • Court Ordered Visitations • Doctor or Dentist Appointments • Observations of religious holidays or ceremonies For your child’s protections as well as the other children and staff, you will need to keep your child home if they have the following: • Sore Throat and/or Cough • Discharge from the eyes or ears, or severe nasal discharge • Diarrheas and/or vomiting • Temperature over 100 degrees Fahrenheit • Contagious Disease • Rash In the case of a contagious disease, please contact the office immediately. If your child contracts any of the following, notification is necessary: measles, mumps, chicken pox, head lice, conjunctivitis or strep throat. All parents will be notified as soon as possible. Your cooperation is appreciated. If your child becomes ill during the day, you will be contacted to come and pick him/her up immediately. Your cooperation with getting here in a timely manner is required.

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Medications

No medication of any kind (prescription or over the counter) will be administered to a student without a parent’s instruction and approval for each medication and the doctor’s authorization on the school authorization form. Please make sure the medicine is in its original container and must have the child’s name and dosage information. All medications must be given to the office or teacher and is to never to be left in your child’s cubbies.

Clothing

We recommend your child be dresses in clothes that do not restrict participation in activities. Comfortable play clothes are necessary. Please label all clothing that can be removed and lost such as mittens, scarves, coats and hats. We frequently use the outdoor playground so please dress your child appropriately for outdoor play. Please provide an extra change of clothes to be kept in your child’s cubbies.

Behavior and Discipline

Participants are always expected to exhibit appropriate behavior. If a child is acting inappropriate, our staff will have a discussion to find out where the problem may be. We will attempt to make the changes necessary to eliminate inappropriate behavior. Positive statements and redirection of negative behavior are practiced. When this fails, these guidelines will be implemented:

• A conduct report is written by the staff and discussed with the parents • A copy of this report is given to the parent • A conversation will take place with the staff to discuss further actions if necessary

If appropriate behavior continues and a child has had 3 conduct reports written on him/her during the program, then the following procedures will take place:

1. The child will be suspended from class for a minimum of 2 classes

2. Upon return, a behavior contract will be implemented

3. If the problem continues after the suspension and contract, the child will be removed from the program.

The following are examples of inappropriate behavior:

• Hitting, kicking, physical abuse, throwing objects towards staff or participation • Defiance of Authority • Abuse of equipment supplies or facilities

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Toys from Home

Because toys from home can be lost or misused by other children, they are not permitted at school. Each class has an ample supply of age appropriate toys for the children to use.

Special Weeks

During the school year each child will get a chance to have his/her own “Special Week.” During this week children will have the opportunity to feel important, to be the highlight of the week. The child will be the line leader, special helper, etc. They will be able to display a poster in their room of special things about themselves.

School Holidays

• Close at noon on New Year’s Eve Day • New Year’s Day • Martin Luther King Jr. Day • Presidents Day • Memorial Day • 4th of July • Labor Day • Veterans Day • Thanksgiving Day & the Friday after • Christmas Eve • Christmas Day

Emergencies

In case of an accident, parents will be notified immediately. Should the parent or authorized emergency contact person not be reached, the child will be taken to the hospital listed on the emergency card or the nearest hospital if one is not specified. Continued efforts will be made to reach the parent.

Special Request (If applicable)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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Parent Sign In/ Sign Out Procedures

Each child must be accompanied by a parent or adult to the child’s assigned classroom. According to the State Regulations, it is MANDATORY for the responsible parent or adult to sign the child in with a full signature when they enter the facility. When the child is picked up, the responsible parent or adult must sign the child out with a full signature.

The teacher can help and support the parent if events or problems are communicated. Please feel free to hand the teacher a note about any issues, which are particularly stressful for the child. A follow-up appointment or telephone call can be helpful.

A parent may authorize another person to pick up his or her child by:

1. Listing the authorized person on the child’s emergency contact card. 2. Giving written and dated notice to the director authorizing your child’s release

to someone else. 3. A phone call may also be accepted if you talk to the director. You will need to

give specific information to verify that it is you.

A photo driver’s license or photo I.D. card will be required of any individual picking up children. NO CHILD WILL BE RELEASED TO AN UNAUTHORIZED PERSON OR A PERSON WITHOUT PROPER I.D., EVEN IF THE CHILD KNOWS THE PERSON.

The parent is responsible for notifying the office if the child is to be absent or late.

If Bear Country staff cannot reach the parent, any child absent 10 consecutive days will be dropped from the program.

Custody Issues- We are legally unable to refuse visitation or the privilege of picking up children to a parent unless we have a CERTIFICATE OF CUSTODY AND/OR A RESTRAINING ORDER from the legal guardian with physical custody. It is the parent’s responsibility to furnish a copy of the court order for your child’s file.

I have read and understand the PARENT SIGN IN/ SIGN OUT PROCEDURES.

___________________________________ ____________ Parent/ Guardian Signature Date

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Permission to Photograph

I, ________________________________, give permission for Bear Country to (Parent/ Guardian Name)

photograph my child, ___________________________for the following purposes: (Child’s Name)

Types of Uses: Please Check One: Still Photographs: Grant Permission | Decline Permission

Display in my personal scrapbook

Give photographs possibly containing your child to current clients

Display in facility’s scrapbook or bulletin boards, show to current and prospective clients

Display still photos on Bear Country Website*

Display still photos on Bear Country Facebook

Videos: Grant Permission | Decline Permission

Give Videos to current parents

YouTube promotional video

Other

*Only first names and possibly last initials (in the event of two or more children with the same first name) will be displayed on the facility website. I understand that it is my responsibility to update this form if I no longer wish to authorize one or more of the above uses. I agree that this form will remain in effect during the tern of my child’s enrollment.

___________________________________ _____________ Parent/ Guardian Signature Date

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EFFECTS OF

LEAD EXPOSURE

Children 1-6 years old are the most at

risk for lead poisoning.

x

x

x

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/HDG�SRLVRQLQJ�FDQ��KDUP��D�FKLOG·V� �nervous system and brain when

they are still forming, causing

learning and behavior problems

that may last a lifetime.

Lead can lead to a low blood count

(anemia).

Even small amounts of lead in the

body can make it hard for children

to learn, pay attention, and

succeed in school.

Higher amounts of lead exposure

can damage the nervous system,

kidneys, and other major organs.

Very high exposure can lead to

seizures or death.

POTENTIAL SOURCES OF LEAD

x

xxx

x

x

x

x

x

x

Old paint, especially if it is chipped

or peeling or if the home has been

recently repaired or remodeled

House dust

Soil

Some imported dishes, pots and

water crocks. Some older

dishware, especially if it is cracked,

chipped, or worn

Work clothes and shoes worn if

working with lead

Some food, candies and spices

from other countries

Some jewelry, toys, and other

consumer products

Some traditional home remedies

and traditional make-up

Lead fishing weights and lead

bullets

Water, especially if plumbing

materials contain lead

SYMPTOMS OF LEAD EXPOSURE

Most children who have

lead poisoning do not

look or act sick.

Symptoms, if any, may

be confused with

common childhood

complaints, such as

stomachache,

crankiness, headaches,

or loss of appetite.

OPTIONS FOR LEAD TESTING

A blood lead test is free if you have

Medi-Cal or if you are in the Child

Health and Disability Prevention

Program (CHDP). Children on

Medi-Cal, CHDP, Head Start, WIC, or

at risk for lead poisoning, should be

tested at age 1 and 2. Health

insurance plans will also pay for this

WHVW��$VN�\RXU�FKLOG·V�GRFWRU�DERXW��blood lead testing.

For more information, go to the

California Childhood Lead Poisoning

3UHYHQWLRQ�%UDQFK·V�ZHEVLWH�DW�www.cdph.ca.gov/programs/clppb, or

call them at (510) 620-5600.

(The information and images found on

this publication are adapted from the

California Department of Public Health

Childhood Lead Poisoning Prevention

Program.)

1/2019

13

http://www.cdph.ca.gov/programs/clppb

www.cdph.ca.gov/programs/clppb

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he Damaging Effects of Lead

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x Lead poisoning can harm a

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brain when they are still

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body can

make it hard

posure on Children

forming.

Lead can lead to a low blood

count (anemia).

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LEAD POISONING FACTS

x

x

x

x

x

x

Buildup of lead in the body is referred to as lead poisoning.

Lead is a naturally occurring metal that has been used in many products and is harmful to the human body.

There is no known safe level of lead in the body.

Small amounts of lead in the body can cause lifelong learning and behavior problems.

Lead poisoning is one of the ildren 1-6 years old are the most common environmental oillnst eastse riss ik fon Car leliafodrni poaiso chnildinreg. n.

The United States has taken many steps to remove sources of lead, but lead is still around us.

IN THE US:

x

x

x

Lead in house paint was severely reduced in 1978.

Lead solder in food cans was banned in the 1980s.

Lead in gasoline was removed in the early 1990s.

LEAD IN TAP WATER

The only way to know if tap water has lead is to have it tested.

Tap water is more likely to have lead if:

x�� Plumbing materials, including fixtures, solder (used for joining metals), or service lines have lead in them;

x Water does not come from a public water system (e.g., a private well).

To reduce any potential exposure to lead in tap water:

x

x

x

Flush the pipes in your home Let water run at least 30 seconds before using it for cooking, drinking, or baby formula (if used). If water has not been used for 6 hours or longer, let water run until it feels cold(1 to 5 minutes.)*

Use only cold tap water for cooking, drinking, or baby formula (if used) If water needs to be heated, use cold water and heat on stove or in microwave.

Care for your plumbing Lead solder should not be used for plumbing work. Periodically remove faucet strainers and run water for 3-5 minutes.*

x Filter your water- Consider using a water filter certified to remove lead.

WARNING!

Some water crocks have lead. Do not give a child water from a water crock unless you know the crock does not have lead.

(*Water saving tip: Collect your run-ning water and use it to water plants not intended for eating.)

For information on testing your water for lead, visit The Environmental Pro-tection Agency at www.epa.gov/lead/ protect-your-family-exposures-lead or call (800) 426-4791.

You can also visit The California De-SDUWPHQW�RI�3XEOLF�+HDOWK·V�ZHEVLWH�at https://www.cdph.ca.gov.

14

https://www.cdph.ca.gov.

www.epa.gov/lead

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PERSONAL RIGHTS Child Care Centers

Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers. (a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are

not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her

needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,

threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.

(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child.

(6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing

agency.

THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

NAME

ADDRESS

CITY ZIP CODE AREA CODE/TELEPHONE NUMBER

DETACH HERE

TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE: PLACE IN CHILD'S FILE

Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:

ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the California Code of Regulations, Title 22, at the time of admission to:

(PRINT THE ADDRESS OF THE FACILITY)(PRINT THE NAME OF THE FACILITY)

(PRINT THE NAME OF THE CHILD)

(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)

(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE)

LIC 613A (8/08)

15

( )( )

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CONSENT FOR EMERGENCY MEDICAL TREATMENT-Child Care Centers Or Family Child Care Homes

AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO

_________________________________________ TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE FACILITY NAME

PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR

__________________________________________________ . THIS CARE MAY BE GIVEN UNDER NAME

WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD

NAMED ABOVE.

DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE

CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:

HOME ADDRESS

HOME PHONE

LIC 627 (9/08) (CONFIDENTIAL)

WORK PHONE

16

State of California – Health and Human Services Agency California Department of Social Services

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES

LIC 700 (10/19) (CONFIDENTIAL) Page 1 of 2

To Be Completed by Parent or Authorized Representative

CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE ( )

ADDRESS NUMBER STREET CITY STATE ZIP BIRTHDATE

PARENT / AUTHORIZED REPRESENTATIVE NAME

LAST MIDDLE FIRST BUSINESS TELEPHONE ( )

HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( )

PARENT / AUTHORIZED REPRESENTATIVE NAME

LAST MIDDLE FIRST BUSINESS TELEPHONE ( )

HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( )

PERSON RESPONSIBLE FOR CHILD

LAST MIDDLE FIRST HOME TELEPHONE ( )

BUSINESS TELEPHONE ( )

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCYNAME ADDRESS TELEPHONE RELATIONSHIP

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCYPHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE

( )

DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( )

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? CALL EMERGENCY HOSPITAL OTHER EXPLAIN: ________________________________

17



NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN

AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)NAME RELATIONSHIP

TIME CHILD WILL BE PICKED UP

SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE

TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE

DATE OF ADMISSION LAST DATE OF ENROLLMENT

18

I have ■■ have not ■■ reviewed the above information with the parent/guardian.

Physician:_______________________________________________ Date of Physical Exam: ___________________________________Address:________________________________________________ Date This Form Completed: _______________________________Telephone: ______________________________________________ Signature ______________________________________________

■■ Physician ■■ Physician’s Assistant ■■ Nurse Practitioner

DATE EACH DOSE WAS GIVEN

/ /

/ /

IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)

PHYSICIAN’S REPORT—CHILD CARE CENTERS(CHILD’S PRE-ADMISSION HEALTH EVALUATION)

PART A – PARENT’S CONSENT (TO BE COMPLETED BY PARENT)

__________________________________________, born ________________________________ is being studied for readiness to enter(NAME OF CHILD) (BIRTH DATE)

_________________________________________ . This Child Care Center/School provides a program which extends from _____ : ____(NAME OF CHILD CARE CENTER/SCHOOL)

a.m./p.m. to ______ a.m./p.m. , __________ days a week.

Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in thisreport to the above-named Child Care Center.

__________________________________________________________ _________________(SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE)

PART B – PHYSICIAN’S REPORT (TO BE COMPLETED BY PHYSICIAN)

Problems of which you should be aware:

Hearing: Allergies:medicine:

Vision: Insect stings:

Developmental: Food:

Language/Speech: Asthma:

Dental:

Other (Include behavioral concerns):

Comments/Explanations:

MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:

LIC 701 (8/08) (Confidential)

1st 2nd 3rd 4th 5thVACCINE

POLIO (OPV OR IPV)

DTP/DTaP/DT/Td

MMR

HIB MENINGITIS

HEPATITIS B

VARICELLA

(DIPHTHERIA, TETANUS AND[ACELLULAR] PERTUSSIS OR TETANUSAND DIPHTHERIA ONLY)

(MEASLES, MUMPS, AND RUBELLA)

(REQUIRED FOR CHILD CARE ONLY)

(CHICKENPOX)

(HAEMOPHILUS B)

/ / / / / / / / / /

/ / / / / / / / / // / / // / / / / /

/ / / // / / /

SCREENING OF TB RISK FACTORS (listing on reverse side)

■■ Risk factors not present; TB skin test not required.

■■ Risk factors present; Mantoux TB skin test performed (unless

previous positive skin test documented).___ Communicable TB disease not present.

STATE OF CALIFORNIAHEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING

PAGE 1 OF 2

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RISK FACTORS FOR TB IN CHILDREN:

* Have a family member or contacts with a history of confirmed or suspected TB.

* Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America).

* Live in out-of-home placements.

* Have, or are suspected to have, HIV infection.

* Live with an adult with HIV seropositivity.

* Live with an adult who has been incarcerated in the last five years.

* Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents innursing homes.

* Have abnormalities on chest X-ray suggestive of TB.

* Have clinical evidence of TB.

Consult with your local health department’s TB control program on any aspects of TB prevention and treatment.

LIC 701 (8/08) (Confidential) PAGE 2 of 2

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CHILD’S PREADMISSION HEALTH HISTORY - PARENT/AUTHORIZED REPRESENTATIVE REPORT


CHILD’S NAME SEX BIRTHDATE

PARENT / AUTHORIZED REPRESENTATIVE NAME DOES PARENT / AUTHORIZED REPRESENTATIVE LIVE IN HOME WITH CHILD?

PARENT / AUTHORIZED REPRESENTATIVE NAME DOES PARENT / AUTHORIZED REPRESENTATIVE LIVE IN HOME WITH CHILD?

IS / HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?

DATE OF LAST PHYSICAL/MEDICAL EXAMINATION

DEVELOPMENTAL HISTORY (*For infants and preschool-age children only)WALKED AT*________________ MONTHS

BEGAN TALKING AT* ________________ MONTHS

TOILET TRAINING STARTED AT* ________________ MONTHS

PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:

� Chicken Pox � Asthma � Rheumatic

Fever � Hay Fever

DATES � Diabetes � Epilepsy � Whooping

Cough � Mumps

DATES � Poliomyelitis � Ten-Day

Measles (Rubeola)

� Three-Day Measles (Rubella)

DATES

SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS

DOES CHILD HAVE FREQUENT COLDS? YES NO

HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF

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DAILY ROUTINES (*For infants and preschool-age children only)WHAT TIME DOES CHILD GET UP?*

WHAT TIME DOES CHILD GO TO BED?*

DOES CHILD SLEEP WELL?*

DOES CHILD SLEEP DURING THE DAY?*

WHEN?* HOW LONG?*

DIET PATTERN:(What does child usually eat for these meals?)

BREAKFAST

LUNCH

DINNER

WHAT ARE USUAL EATING HOURS?

BREAKFAST

LUNCH

DINNER

ANY FOOD DISLIKES? ANY EATING PROBLEMS?

IS CHILD TOILET TRAINED?* YES NO

IF YES, AT WHAT STAGE:*

ARE BOWEL MOVEMENTS REGULAR?*

YES NO

WHAT IS USUAL TIME?*

WORD USED FOR “BOWEL MOVEMENT”* WORD USED FOR URINATION*

PARENT / AUTHORIZED REPRESENTATIVE EVALUATION OF CHILD’S HEALTH

IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?

YES NO

IF YES, NAME OF DOCTOR:

DOES CHILD TAKE PRESCRIBED MEDICATION(S)?

YES NO

IF YES, WHAT KIND AND ANY SIDE EFFECTS:

DOES CHILD USE ANY SPECIAL DEVICE(S):

YES NO

IF YES, WHAT KIND: DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?

YES NO

IF YES, WHAT KIND:

PARENT/ AUTHORIZED REPRESENTATIVE EVALUATION OF CHILD’S PERSONALITY

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HOW DOES CHILD GET ALONG WITH PARENT / AUTHORIZED REPRESENTATIVE, BROTHERS, SISTERS AND OTHER CHILDREN?

HAS THE CHILD HAD GROUP PLAY EXPERIENCES?

DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)

WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?

REASON FOR REQUESTING DAY CARE PLACEMENT

PARENT/AUTHORIZED REPRESENTATIVE SIGNATURE DATE

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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

IMPORTANT INFORMATION FOR PARENTS

CAREGIVER BACKGROUND CHECK PROCESS CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

The California Department of Social Services works to protect the safety of children in child care by licensing child care centers and family child care homes. Our highest priority is to be sure that children are in safe and healthy child care settings. California law requires a background check for any adult who owns, lives in, or works in a licensed child care home or center. Each of these adults must submit fingerprints so that a background check can be done to see if they have any history of crime. If we find that a person has been convicted of a crime other than a minor traffic violation or a marijuana- related offense covered by the marijuana reform legislation codified at Health and S afety Code sections 11361.5 and 11361.7, he/she cannot work or live in the licensed child care home or center unless approved by the Department. This approval is called an exemption.

A person convicted of a crime such as murder, rape, torture, kidnapping, crimes of sexual violence or molestation against children cannot by law be given an exemption that would allow them to own, live in or work in a licensed child care home or center. If the crime was a felony or a serious misdemeanor, the person must leave the facility while the request is being reviewed. If the crime is less serious, he/she may be allowed to remain in the licensed child care home or center while the exemption request is being reviewed.

How the Exemption Request is Reviewed We request information from police departments, the FBI and the courts about the person’s record. We consider the type of crime, how many crimes there were, how long ago the crime happened and whether the person has been honest in what they told us.

The person who needs the exemption must provide information about: • The crime

• What they have done to change their life and obey the law

• Whether they are working, going to school, or receiving training

• Whether they have successfully completed a counseling or rehabilitation program

The person also gives us reference letters from people who aren’t related to them who know about their history and their life now.

We look at all these things very carefully in making our decision on exemptions. By law this information cannot be shared with the public.

How to Obtain More Information As a parent or authorized representative of a child in licensed child care, you have the right to ask the licensed child care home or center whether anyone working or living there has an exemption. If you request this information, and there is a person with an exemption, the child care home or center must tell you the person’s name and how he or she is involved with the home or center and give you the name, address, and telephone number of the local licensing office. You may also get the person’s name by contacting the local licensing office. You may find the address and phone number on our website. The website address is http://ccld.ca.gov/contact.htm.

LIC 995 E (10/09)

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http://ccld.ca.gov/contact.htm

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING DIVISION

CHILD CARE CENTERNOTIFICATION OF PARENTS’ RIGHTS

PARENTS’ RIGHTSAs a Parent/Authorized Representative, you have the right to:

1. Enter and inspect the child care center without advance notice whenever children are in care.

2. File a complaint against the licensee with the licensing office and review the licensee’s public filekept by the licensing office.

3. Review, at the child care center, reports of licensing visits and substantiated complaints against thelicensee made during the last three years.

4. Complain to the licensing office and inspect the child care center without discrimination or retaliationagainst you or your child.

5. Request in writing that a parent not be allowed to visit your child or take your child from the childcare center, provided you have shown a certified copy of a court order.

6. Receive from the licensee the name, address and telephone number of the local licensing office.

Licensing Office Name: _________________________________________________

Licensing Office Address: _________________________________________________

Licensing Office Telephone #: _________________________________________________

7. Be informed by the licensee, upon request, of the name and type of association to the child carecenter for any adult who has been granted a criminal record exemption, and that the name of theperson may also be obtained by contacting the local licensing office.

8. Receive, from the licensee, the Caregiver Background Check Process form.

NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO APARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE�POSES A RISK TO CHILDREN IN CARE.

For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov

LIC 995 (9/08) (Detach Here - Give Upper Portion to Parents)

AC K N OW L E D G E M E N T O F N OT I F I C AT I O N O F PA R E N T S ’ R I G H T S(Parent/Authorized Representative Signature Required)

I, the parent/authorized representative of ___ _____________________________________________ , havereceived a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and theCAREGIVER BACKGROUND CHECK PROCESS form from the licensee.

_____________________________________

______________________________________________ __________________Date

NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given toparent/authorized representative.

For the Department of Justice “Registered Sex Offender”database go to www.meganslaw.ca.gov

LIC 995 (9/08)

Signature (Parent/Authorized Representative)

Name of Child Care Center

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