1 per child

Mercy Child Development Center & PreschoolEnrollment Information

Child’s Information

Father’s Information

Mother’s Information

Marital status of parents: Married______ Divorced_____ Single______ Separated_____ Foster Parent______ In cases other than married with who does the child reside: _________________________________________

Insurance Information-Must be completed.

By checking this box and typing your name in the signature field, you are stating that the information you'veprovided herein is true and correct to the best of your knowledge.

Signature: Date:

Does your child have health insurance? ____Yes, Company _______________ ID#___________________

Does your child have dental insurance? ____Yes, Company________________ ID#___________________

_____No we do not have health insurance _____ No we do not have dental insurance

Name: ___________________________________ Primary Email Address: _________________________

Home Address: ____________________________ City: ________________ State: ______ Zip: ________

Home Phone: ____________________ Cell Phone: ___________________ Cell Carrier: ______________

Employer: _________________________ Dept: ____________ Work Phone: _______________________

Child’s Full Name: ________________________________________________Nickname: ______________

Birth Date: _________ Sex: ____ Start Date: __________________ School (if school age): _____________

Please list all Allergies: ___________________________________________________________________

*MUST INCLUDE A COPY OF CHILD'S BIRTH CERTIFICATE FOR FILE (All but school age)____

Name: ___________________________________ Primary Email Address: _________________________

Home Address: ____________________________ City: ________________ State: ______ Zip: ________

Home Phone: ____________________ Cell Phone: ___________________ Cell Carrier: ______________

Employer: _________________________ Dept: ____________ Work Phone: _______________________

(one per family required)

(one per family required)

Medical/Dental Consent

In the event reasonable attempts to contact the parent/guardian have been unsuccessful, I,____________________________(Mother/Father) of_________________________, do hereby give my permission to the personnel of Mercy Child Development Center & Preschool, to secure and authorize such emergency medical/dental care and /or treatment at _______________(*hospital of choice) as my child might require while under supervision of the Child Development Center. I agree to pay all costs and fees contingent on any emergency treatment needed for my child as secured and authorized under this consent. This authorization shall remain effective during the entire period that aforesaid minor is enrolled at Mercy Child Development Center & Preschool.

*Physician & Dentist must be listed.

________________________ ___________________________________ ____________________ Physicians name City, State Phone ________________________ ___________________________________ ____________________ Dentists name City, State Phone

Screening Information: Does your child visit a dentist: yes___ no___ Had a Lead Test: yes___ no___If yes please provide the date of the last screening. Dental: ____________ Lead: ____________(Regardless of whether or not your child has had a dental screening you must list a dental provider above.)

*If you wish for your child to be treated at a hospital other than Mercy, we will contact you so that you may make arrangements for transportation. In the event of a situation that we judge to be an emergency, the child will be taken to Mercy Medical Center Emergency room.

Emergency Contact and Authorized Pick Up Persons

Please list persons to contact in the event parents cannot be reached and are authorized to pick up child: It is the responsibility of the parents to notify the center, in writing, of any changes.

Signature: ___________________________________________________ Date: _________________

Are there any custody orders or restraining orders for persons who may attempt to pick up or have contact with the child while in care at the center? Are there any people that may NOT pick up your child? Name: __________________________________Name:__________________________________

1st Contact/Pick up Is this person over 18 years of age? ______yes _______no Name: __________________________________ Relationship to child: ______________________ Home Phone: ________________ Work Phone: _______________ Cell Phone: _______________

2nd Contact/Pick up Is this person over 18 years of age? ______yes _______no Name: __________________________________ Relationship to child: ______________________ Home Phone: ________________ Work Phone: _______________ Cell Phone: _______________

3rd Contact/Pick up Is this person over 18 years of age? ______yes _______no Name: __________________________________ Relationship to child: ______________________ Home Phone: ________________ Work Phone: _______________ Cell Phone: _______________

4th Contact/Pick up Is this person over 18 years of age? ______yes _______no Name: __________________________________ Relationship to child: ______________________ Home Phone: ________________ Work Phone: _______________ Cell Phone: _______________

If at any time the center does not feel comfortable releasing your child to a pick up person, the parent will be notified to make other arrangements. Mercy does not assume responsibility for care once the child is released to an authorized pick up person.

Address

Address

By checking this box and typing your name in the signature field, you are stating that the information you've provided herein is true and correct to the best of your knowledge.

Mercy Child Development Center & Preschool Permission Slip

Community Participation

Media

Sunscreen

Parent Handbook

As a parent, I understand I have the right to change this at any time and can do so by completing a new permission slip.

Signature_________________________________________Date_________________

I _____________________ (parent) understand it is my responsibility to read and abide by all Mercy Child Development Center policies contained in the Parent Handbook. The handbook can be found at mercydubuque.com/parentinformation. I understand that Mercy CDC reserves the right to unilaterally change, modify, amend, add, rescind or terminate any or all Child Development Center policies, at any time, with our without notice, as it determines appropriate in its sole discretion. I further acknowledge that failure to comply with policies and procedures of the CDC may result in removal of my children from the Mercy Medical Center CDC.

I give permission for Mercy Child Development Center & Preschool staff to apply a sunscreen of SPF 30 or higher to my child (age 6 months or older) as specified below for outdoor activities.

I do not know of any allergies my child has to sunscreen. Staff may use the sunscreen of their choice following the directions or recommendations printed on the bottle. My child is allergic to some sunscreens. Please use only the following brand sunscreen I have provided________________________________________. For medical or other reasons, please do not apply sunscreen to the following areas of my child’s body: _________________________________________.

I do___/do not___give permission for my child ________________________________ to be photographed or video taped by autho rized person of Mercy Child Development Center & Preschool. If photos are used for any purpose other then within the center parents will be contacted for specific permission.

As part of our educational program in the preschool classrooms, the children may occasionally be taken on field trips away from Mercy Child Development Center. These trips may include scenic walks and bus rides to points of interest. These excursions will help broaden the preschooler’s experiences and knowledge.

When my child is age appropriate I do____/do not ____ give permission for my child ______________________________to go on community events, activities, or field trips.

By checking this box and typing your name in the signature field, you are stating that theinformation you've provided herein is true and correct to the best of your knowledge.

Mercy Child Development Center & Preschool Secured Access Information Form

Mercy Child Development Center & Preschool’s secured access system requires that each authorized user have an access “touch chip” in order to be able to enter the Center. Each family will be issued a maximum of two chips. In most cases, one chip will be assigned to each parent. If your situation is that one parent primarily drops off and picks up the children and that another adult who is not the parent, (grandma or nanny for example) also frequently and consistently picks up the children, then you may ask to have that individual assigned an access chip instead of a parent. Please keep in mind that the system is designed to limit access to the Center, so authorization given to those other than parents should be considered carefully.

Adults who need access to the Child Development Center & Preschool on an infrequent basis, will need to call into the Center on a courtesy phone and be given clearance before being able to enter the Center.

Please complete the following information. PLEASE PRINT!!

Child’s/children’s names_____________________________________________________________

Two (2) access chips will be authorized to each family. Complete the following information for those who you would like to have authorized for access.

Mother’s name____________________________________ last four of social security # __________

Father’s name____________________________________ last four of social security # __________

If there is another adult who has frequent and consistent responsibility for picking up the children, you may wish for them to be given an access chip. Please keep in mind that if you wish them to have authorization, then only one parent will be able to have an access chip.

Name___________________________________________ last four of social security # __________

Relationship to child________________________________________________________________

Signature___________________________________________________Date__________________

By checking this box and typing your name in the signature field, you are stating that the information you've provided herein is true and correct to the best of your knowledge.

Request for Electronic Communication Agreement

Daily communication through HiMama or other electronic program: Mercy Child Development Center & Preschool (MCDC) can now deliver daily communication regarding each child’s daily activities, meals, toileting and so much more. MCDC will be delivering all communication through this form, unless you choose to opt out. MCDC has partnered with HiMama to provide an online and app version of daily communication. HiMama has a Secure Sockets Layer (SSL) certificate, ensuring all data passed between the HiMama server and your browser remains private. However, with any data system there may be risks associated with the technology and it could be hacked and or have a security compromise. MCDC will retain all log in information and passwords in a secure location and the information will not be shared by Management outside the agency. MCDC staff monitors system security notices and updates per information provided. By signing this agreement you are providing consent that you are willing to accept the risk associated with the product that staff use and you will hold MCDC harmless should a breach occur.

Note that sometimes other children in the center may feature in photos, videos or stories of your child. By giving your consent you agree not to share photos or videos of any child, other than your own, outside MCDC without permission.

How to withdraw Consent: You may withdraw your consent to receive communication in electronic form by updating this form at any time. At that point you will no longer receive updates through HiMama and will be given a paper version of daily communication.

___ I request that daily communications from MCDC be delivered to me through HiMama or other electronic program. I understand that this form of communication may have risks associated with it including security, creating a risk of improper disclosure to unauthorized individuals. I am willing to accept this risk, and will not hold MCDC responsible should such incident occur.

___ I elect to opt out of daily communication through HiMama, by checking this I understand that MCDC will not communicate with me through HiMama, unless I sign an agreement in the future.

Name of Child/Children: _______________________________________________________________________

Email:

To link your electronic daily communication we will use the emails currently on file. You will receive an email

confirming this communication through HiMama with directions for signing on. If you wish to use a different

email or add an additional email please include them below.

Name: _________________________________ Email Address: ________________________________________

Name: _________________________________ Email Address: ________________________________________

By checking this box and typing your name in the signature field, you are stating that the information you've provided herein is true and correct to the best of your knowledge.

Parent Signature: ______________________________________________Date: _________________________

___

The U.S. Department of Agriculture prohibits

discrimination against its customers, employees,

and applicants for employment on the bases of

race, color, national origin, age, disability, sex,

gender identity, religion, reprisal, and where

applicable, political beliefs, marital Status,

familial or parental status, sexual orientation, or

all or part of an individual’s income is derived

from any public assistance program, or protected

genetic information in employment or in any

program or activity conducted or funded by the

Department. (Not all prohibited bases will apply

to all programs and/or employment activities.)

If you wish to file a Civil Rights program

complaint of discrimination, complete the USDA

Program Discrimination Complaint Form, found

online at

http://www.ascr.usda.gov/complaint_filing_cust.h

tml. Or at any USDA office, or call (866)632-

9992 to request the form. You may also write a

letter containing all of the information requested

in the form. Send your completed complaint

form or letter to us by mail at U.S. Department of

Agriculture, Director, Office of Adjudication,

1400 Independence Avenue, S.W., Washington,

D.C. 20250-9410, by fax (202)690-7442 or email

at program.intake@usda.gov.

Individuals who are deaf, hard of hearing or have

speech disabilities may contact USDA through

the Federal Relay Service at (800) 877-8339; or

(800) 845-6136 (Spanish).

Iowa Department of Education Bureau of Nutrition and Health Services

400 E. 14th St., Grimes State Office Building Des Moines, Iowa 50319-0146

Phone: (515) 281-5356

Contacts

If you are a parent of children receiving child care or a

child care facility interested in participating in the CACFP,

or have questions about the Program, contact USDA at (703) 305-2590 or the Iowa State agency at:

Iowa Department of Education

Bureau of Nutrition and Health Services Grimes State Office Building

Des Moines, Iowa 50319-0146

Phone: (515) 281-5356

Iowa Nondiscrimination Statement: “It is the policy of this CNP provider not to discriminate on

the basis of race, creed, color, sex, sexual orientation, gender identity, national origin, disability, age, or religion

in its programs, activities, or employment practices as

required by the Iowa Code section 216.6, 216.7, and 216.9. If you have questions or grievances related to

compliance with this policy by this CNP Provider, please

contact the Iowa Civil Rights Commission, Grimes State Office Building, 400 E. 14th St. Des Moines, IA 50319-

1004; phone number 515-281-4121, 800-457-4416;

website: https://icrc.iowa.gov/.”

3.2 million children and almost 112,000 older adults

Iowa Department of Education Bureau of Nutrition and Health Services

400 E. 14th St., Grimes State Office Building Des Moines, Iowa 50319-0146

Phone: (515) 281-5356

Each day, more than 3.2 million children and 112,000 older adults participate in CACFP. Through CACFP, participants’ nutritional needs are met on a daily basis. The program plays a vital role in improving the quality of child care and making it affordable for many low-income families.

1 per child

Iowa Child and Adult Care Food Program

Child Care Enrollment Form

Times of Care Regular Days of Care Meals Served During Care Ethnicity/Race*

Last Name, First Name

Date of Birth Arrival Departure

M T W Th F S S B AM Sn

Lu PM Sn

D E Sn Ethnicity Race

*Ethnicity (Select one and enter in the chart above): H=Hispanic or Latino or N=Not Hispanic or LatinoRace (Select one or more and enter in the chart above): W=White, B=Black or African American, I=American Indian or Alaska Native, A=Asian, and P=Pacific IslanderThis information is requested by the Federal Government in order to monitor compliance with civil rights law. You are not required to furnish this information, but are encouraged to do so. The lawrequires that a program recipient may neither discriminate on the basis of this information nor on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations, thisprogram representative is required to note race/ethnicity on the basis of visual observation or surname.

Infants only (0 to 12 months): I am not enrolling an infant (skip this section)

As a participant in a USDA Child Nutrition Program, our center offers meals to children of all ages. Infant feeding is based on current nutrition guidelines. Infant foods are appropriate for the age and developmental readiness of your infant. Please select (X ) your choice(s) of the following options that will fulfill your infant’s food needs.

I will provide breast milk for my infant. Center formula may be used to supplement feedings if necessary: Yes No

I will provide infant formula for my infant. Name of formula:

I accept the center’s formula for my infant. Name of formula:

I will provide a statement from a medical authority for non-reimbursable formula. Name of formula: ____________________________________

I accept the center’s solid foods (appropriately textured) to be served to my infant as s/he is ready for them, and after I have discussed it with the caregiver.

I will provide solid foods for my infant*. The center may supplement with additional solid foods when my infant needs them: Yes No

*Meals cannot be reimbursed by the CACFP when parents provide solid foods except for medical reasons. DHS licensed centers are required to follow CACFP infant meal pattern

requirements regardless of who supplies the food. Your center can provide a copy of the CACFP infant meal pattern and a list of reimbursable foods upon request.

USDA is an equal opportunity provider and employer.

By checking this box and typing your name in the signature field, you are stating that the information you've provided herein is true and correct

to the best of your knowledge.

Signature: Date:

Your child is enrolled for care in a child care center that participates in the Child and Adult Care Food Program (CACFP). By participating in this Program, the center is meeting Federal meal pattern requirements and receiving reimbursement to assist with food costs. The CACFP requires that parents provide CACFP enrollment information on an annual basis. This form will be placed in our files and treated as confidential information.

Similac Isomil

Revised 6/2014

Women, Infants and Children (WIC) WIC Income Eligibility Guidelines