AGREEMENT

55 PA CODE CHAPTERS 3270.123 &. 181(C); 3280.123 &. 181(c); 3290.123 &. 181(c)

. NAME OF CHILD

FEE AMOUNT

$ PER-DAY -WEEK DAY PAYMENT TO BE MADE

Services to be provided as part of the day care fee (examples; transportation, care, meals, etc.1

CHILD'S ARRIVAL TIME CHILD'S DEPARTURE TI ME PERSON(S) DESIGNATED BY PARENT TO WHOM CHILD MAY BE RELEASED

LATE FEE

$ PER MIN-HR

Extra services to be provided at an additional fee i f applicable

I, the parentlguardian;

received complete written program information at the time of enrollment. (s 3270.12 1, 3280.121, 3290.121)

agree to update the emergency contactlparental sent form information whenever changes occur or every 6 months at a 3270.124, 3280.124, 3290.124)

SIGNATURE-OPERATOR DATE SIGNATURE-PARENT OR GUARDIAN DATE

03892A CY 321 - 12/99

Jones Adley Campus Napper Clark Campus Fort Indiantown Gap Center 1459 Market Street 501 Seneca Street 10-104 Fitzpatrick Hall Armory Harrisburg, PA 171 04 Harrisburg, PA 17104 Fort Indiantown Gap 717-232-8746 717-238-0236 717-861-8351

CHILD'S NAME: LAST FIRST M.I.

ADDRESS: ZIP

BIRTH DATE:

STARTING DATE:

PARENTS FATHER: MOTHER

ADDRESS:

PHONE: HOME: BUS: CELL:

EMPLOYER:

ADDRESS:

CLASS ASSIGNMENT

DAYCARE AFTER SCHOOL

SCHOOL ATTENDING: GRADE:

Has your child had any previous school or day care experience? Yes No

At what facility?

Please tell us about your child's family; names of brothers and sister's grandparents, special nickname, etc. that may help us make your child more comfortable in the school/day care environment.

Toileting is an important part of the pre-school programs and any special information you

can give us about your child's habits will help us work with you and your child in

keeping things as comfortable and personalized as possible.

Is English your child's first languages? - Is there another language

spoken in the home? If so, what language?

Please use the space below to list any medical conditions, allergies, etc, that your child

may have.

Please add any additional information that may help us do a more effective job in

professionally guiding your child.

EMERGENCY INFORMATION

Child's Physician:

Address:

Telephone: Hospital of Choice:

SPECIAL MEDICAL TNFORMATION

Allergies: Asthma:

Convulsions: Other:

Emergency Contact Persons (other than parents)

# 1

Address:

Phone: HomeICell Work

#2

Address:

Phone: HomeICell Work

Persons Authorized to bring or pick-up your child

In case of changes in address, telephone number, place of employment and authorized

pick-up individuals, please notify PNA, Inc immediately. This is for your protection as

well as ours. Please make sure to include yourself and anyone else who may bring or

pick up your child.

EMERGENCY CONTACT I PARENTAL CONSENT FORM

fiItll.0'~ NAME mml*0.1e

-ss

EYERGWY CONTACT PERSON(5) YU~L

MOTHER'S NAMEAEGAL GUARD(AN UX~E IELEC*DYE w t n

- M c m s s

P E R W S J TO WHOM CrPl.0 MAY BE RELEASED YUlL L0011Ess ~ L L E - ~ ~ Y L ~ w ~ E N O I O S . I ~

.NLcSS YUlE

*W M 1- - '-IAIIO* a* M r r u l n w-

'EnKW)(C REVIEW .

WSWESS ~ L L E M O Y W F I

MOnESS

MEDICAL INFORMATION

THE Health department of the State f Pennsylvania requires each child to have a current medical examination before admission to class. The accompanying Health record must be completed and signed by a physician and submitted to Pride of the Neighborhood/FTIG Academies on your child's first day of school.

YES NO I hereby give permission for PNA, Inc. to transport my child, to a hospital and receive medical treatment when I cannot be reached or when delay would be dangerous.

YES NO I hereby give permission for my child to receive anesthesia if necessary for medial treatment during an emergency.

Medical care will be paid by? Name of Insurance

Identification #

Signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.

SIGNATURE (Parent or Guardian) Date

I LENGTWHEffiKl I WEIGHT 1 HEAD CIRCUMFERENCE I BLOOD PRESSURE ImATH TOAOE 2) (BEGINNING AT AGE 3 1

rn

- ' c - - E

5 _p > e a g 8

a

a

i I I I I I I 2 SCREENING TESTS I DATE TEST DONE I NOTE HERE IF RESULTS ARE PENDING OR ABNORMAL 2 LEAD I 1 1

-...-- - .

d - = m $ 3 0 U'

-

PAREYTIOUARDIIY

AOOmESS

WORK P W E .

CY~LDSNIUE. I U S ~

5 DT.PIDTP~~

lNlCM Y llE

PHYSICAL EXAMINATION HEADIEARSIEYESNOSWHROAT TEETH CARDIORESPIRATORY AEDOMENIGI GENlTALllVBREASTS EXTREMITIESNOINTSBACWCHEST SKINLYMPH NODES NEUROLOGIC 6 DEVELOPMENTAL IMMUNUAllONS ( DATE

h

i E ! :

(FIRST1

To Parents: Submission olthis form lo the child careprowder implies consent /or the child care PrOvider to discuss the child's health with the child's c1;n;cian.

PA child care providers must document that enrolled children have received a e appropriate health services and immunizations that meet the current schedule of the American Academy of Pediatrics 141 Northwest %oint Blvd.. Elk Grove Village. IL 60007. The schedule is available at < www.aap.org > or Faxback 8471758.0391 (document H9535 and H9807). Print copies provided by DPW have the schedule on the back of the form.

LBKG % ILE I INICM X ILE I I

q NONE NEXT APPOINTMENT - MONTHNEAR:

DATEOFBIRTH

Health histoty and medical information pertinent to routine child care and emergencies (describe, if any): ONONE

' ~ l l e r~ ies to food or medicine (describe, if any):

ONONE

# = NORMAL

DATE

Y E M U I C A W PROVIDER

AWRESS

PHONE

HOME W O N E

Date of most recent well-child exam:

Do not omit any information. This form may be updated by health professional, (Initial and date new data.) Child care facility needs 2 copies. -

IF ABNORMAL -COMMENTS

I I I DATE DATE DATE COMMENTS

SGNATURE W RIVSlClWOR CPNP

CHILDCARE FACILITY NAME

LICENSE NUMBER

F l C l l l W PWONE.

DATE FORM SIENEO

C W N l Y

INDIVIDUALIZED EDUCATION PLANS (IEP) & INDIVIDUALIZED FAMILY SERVICE PLANS (IFSP)

INFORMATION SHEET (Optional Tool)

Because of the diverse set of needs of the children in your program, it is important to gather as much information about the best ways to educate each child. IEP's and IFSP's are created by service providers working with children with special needs and include this information. The Keystone STARS Performance Standards therefore require each earfy learning provider to request copies of lEPs and IFSPs for the chlldren in their care. This request should be made as early as possible. There are many ways to make this request, and the "sign off sheet" sample below Is one example. Other possibilities include asking during the enrpllment meeting and including the request with the Parent Handbook. Because of the importance of the IEP/IFSP to a child's learning, the program should have a copy before the child begins to attend, if possible.

The iqfdrmation found on an IEP/IFSP is protected by privacy laws including the Health . insurance Portability and Accountability Act (HIPAA). Releases of information may also be required to speak to membek of a chiid's treatment team. Professional development regarding privacy issues, and HIPAA in particular, is highly recommended. . .

Sample Parent Sign-off Sheet

Child's Name:

Your child's growth and development is measured with developmental aisessments. I f your child currently has an IEP/IFSP, it would be beneficial to share a copy of this plan with us so we can work together to ensure that the guidelines are put into practice. You do not have to provide this information if you do not wish to do so.

I am providing a copy of my child's IEP or IFSP.

I am not providing a topy of my child's IEP or IFSP and/or this is not applicable to my child.

Signature: Date:

Printed Name:

Child and Adult Care Food Program Child Enrollment Form

[~nrollment Date: L

Sponsoring Organization CmterIHome Address Addnu

If ma^ Uun I hwn of crr per day, pleac mtxh n uplmaion to this htm.

Is this child of school age? Y e s N o If yes, will additional meals be provided when school is not in session? Y e s N o If yes, pleax specify the meal: Breakfas t -Lunch -Snack -Supper

@E : This child care facility participates in the Child and Adult Care Food Program. In order to receive federal funds. representatives of the sponsoring organization or the State Agency may contact you to verify your child's participation. Please indicate what time apd method of contact you refer:

D a y - Evening - Time

Letter - Telephone (home) i Telephone (work) I - -

--r....--, SilElrhila

Center Adrnmi~ltor/Home Provider m

' In accordance with Fcdcral law mnd U. S. Dcparimcnt oJA$ricullurcpoli~y, this lN1iIulipn is pmhibllcdfmm discn'mindng on the h l s oJrrrcc, color, nafional orilin, 1 4 age or disabilily. (No1 allpmhibilcd &a qpply lo all Pml "w. ' ' T o / l l c a c ~ p I a i n ~ o/discMnofion. wrUc USDA, Dirccfor. of Civfl Rights, Room 326-W, Mit lcn Building, I400 Indepcndcncc Avenuc, SW, Washington, DC20250-9410 or call (102) 720-5964 (voice and TDDJ. USDA is an cqual opportunlry pmvfder and cmploycr.

For Sponsor Use Only

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W R C E ~ Z I I I H O M E SPONSOR USE ONLY Monthly lncome Conversion: Weekly X 4.33; Every 2 Wecb X 2.15: Twice a Month X 2

Categorically eligible for h e bcncfih by Fwd Stamp - or T A W - 70111 Hovrchold Size Monthly Income EUdbuity htcrmlaatioa: Approved Free - Rcduscd Pncc - Paid - Temporary Until Until r until until

Date Veriliulion Notice Sent Response Due From Household Second Notice S a t V~rifiuliott Resull: No change - Free lo Reduced - Free to Paid - R e d u d to Free - Redused to Paid - Reason for Change: Income Household Size Rehued to Coopcnte Chmge in Fwd ShmpTTANF 0th-

Date Notice of Change Sent Verieing Ofisid's Signature Date

FOR HOME SPONSOR USE ONLY Tkr 1 Home Determination

Provider's Previous Yeu's Income (Attach IRS 1040 md Schedule C) or Fwd S m p (Attach Fwd Slunp Verification)

Elldbillty htennlnatlon: Tier I Eligible - Tier I Not Eligible - Tier 2 Mixed -

N e w Parent Fundamentals Please read the following list to make your

child's first day a good day.

1. Bring change of clothes (Season appropriate) in case of an accident.

2 . Bring a blanket or sheet for naptime.

3. Bring a toothbrush. (Children brush after meals).

4. Call 232-8746 for Jones Adley, or 238-0236 or for Napper Clark campus, or 861-8351 for the Fort Indiantown Gap Center before 9am if you plan to bring child after Qam. If you do not call, your child will not be accepted into the centers.

5. Centers close at 6pm. If child is picked up at 6:01 or there after, there is a $10.00 late fee to be paid upon pick up. Fort Indiantown Gap closes promptly at 5:30pm. If child is picked up at 5:3lpm or there after, there is a $10.00 late fee to be paid upon pick up.

6. Feel free to call or visit the center at any time. Parent participation is welcomed and encouraged.