toddlers - two year olds the laurel hill school...welcome to the laurel hill family! reopening plan...

Dear Parents, September is approaching and we are happy to welcome you home to Laurel Hill! These are challenging times that require a comprehensive and thoughtful approach. We at LHS are committed to meeting these challenges and to fully embracing our responsibility to each of our students, staff members, and parents. We want you to know that we are fully committed to a comprehensive response to the current situation and to helping to reduce uncertainty as much as possible. Welcome to the Laurel Hill family!

REOPENING PLAN 2020 Preschool, Toddler, & Infant

Please read the Reopening Plan 202(Preschool Edition) which outlines in greater detail, the health protocols and operating procedures Laurel Hill will be instituting this year in our school. You

can find it in the Parent Portal section of our website.

1

TODDLER (2 yr.old) ORIENTATION

In order to alleviate some of the anxiety associated

with the first days of school, and to facilitate a smooth acclimation to a new environment, we

have an orientation period for our Toddler program.

This year, our orientation sessions

have been adjusted to meet the challenges

presented by our current circumstances. We have added additional days of

orientation so as to prevent crowding, and

observe social distancing guidelines while still maximizing

the effectiveness of each child’s orientation

experience.

PLEASE LOOK FOR THE ORIENTATION SCHEDULE

(Enclosed Here)

FOR COMPLETE DETAILS AND TIMES.

ENCLOSED PLEASE FIND IMPORTANT

FORMS THAT MUST BE SUBMITTED TO

SCHOOL

DOWNLOAD ALL THE FORMS

ATTACHED

SUBMIT FORMS TO

THE SCHOOL OFFICE

TODDLERS - TWO YEAR OLDS

The Laurel Hill School School Orientation Manual 2020-2021

School Communications

Teacher’s Website Every classroom teacher has their own “class website.” The website will contain information on all activities and events taking place in your child’s class. It will outline the many activities your child will be introduced to each month. We encourage you to review and utilize the activities at home with your child when possible.

Weekly E-Mail Pertinent information is sent out every Friday via e-mail. This is the only mode of communication that will be used during the upcoming

school year. It is imperative that we have a current, preferred e-mail address for every student. We urge you to submit your preferred e-mail address immediately if you have not already done so. Be certain to check your e-mail for up-to-date events and happenings each week. It would be most helpful if you would set spam filters, particularly if you’re an AOL user, to allow LHS to get through ([email protected]).

Weather Emergencies

A storm emergency may require the closing of school. The decision to close school (or suspend bus service) due to snow, high winds, or heavy rains is made on the basis of safety to children and commuting staff. Local road conditions are carefully assessed. You will be notified by our automatic telephone system (Parent Reach) regarding school closure if a weather emergency occurs. Announcements will also be made on our website www.laurelhillschool.org

2

2020-2021

Parent Conferences Virtual Meetings

Parent-Teacher conferences are scheduled during the school year will be held virtually. Your child's total performance is reviewed. Issues pertaining to skills, achievement, social and emotional growth, and creative expression are profiled. A written summary of the conference will be given to you. The conference is a dialogue between you, your teacher and school administrators. We learn a great deal through your observations and comments. During the school year you are welcome to meet with us at any time. Please don't wait for your conference to review pressing matters.

http://www.laurelhillschool.org

3

We Love to Talk To Our Parents…

Communicating with your child’s teacher . . .

•Your child’s well being is our highest priority. The happiness and development of your child are enhanced by the feedback we receive from you. Please call us on any matter concerning your child! Many problems are easily solved if we work together early. Information we receive from you suggests where our program is succeeding, or requires modification for your child. Please do not hesitate to call. • Calling LHS Call our front desk to leave a message. We will make sure to pass it to your child’s teacher. If you desire a call back and it is not an emergency, it shall be made after school, or other time your teacher is not in class.

• Texting This is a big “No-no!” We do not support texting. Laurel Hill faculty turn their cell phones off while in class. This enables them to keep full attention on their students and lessons. We are sure you agree that receiving and replying to texts may be massive through-the-day distractions.

• Meetings Schedule a virtual meeting. You don’t need to wait for progressive report time. A meeting may be arranged after the school day or earlier, if possible.

With Laurel Hill administrators . . . • By phone or by scheduled virtual meeting Call and we will be happy to speak with you; and

certainly, if an admin is not available your call will be returned asap. • Email - Robert H. Stark, Headmaster: [email protected] - Helen Stark, Educational Director: [email protected] - Yosefa Klein-Karchmar, PreSchool Director: [email protected]

Clothing, Toys & Valuables

Clothing: In order to avoid lost clothing, please label all coats, gloves, hats, scarves, boots and sweaters. It will make return of these articles easier.

Toys: Please refrain from sending any toys including trading cards, and hand-held electronic games.

Valuables: Please do not send in costly items such as jewelry.

4

LUNCH & SNACKS This year, our school food service program ( My Hot lunch Box ) is temporarily discontinued.

Classes will eat together, in their own

classroom or designated outdoor area,

while maintaining social distance. All

students will be required to bring their

own food and water to school each

day in a lunch box with an ice pack, as

well as any snacks they may need for

the

Our nutrition program aims at

controlling junk food intake by our

students. Please refrain from sending

candy to school. Your cooperation in

this matter is appreciated.

2020-2021

Nutrition Our program in nutrition

includes cooking on a regular basis. Dishes may range from casseroles to dessert - all prepared by the children. Teachers will send home requests

for items such as an egg, a potato, or a cup of milk.

🎉 Birthdays 🎉 Birthdays are very special events and will be celebrated happily in your child's class. Unfortunately, parent participation will not be possible due to current health protocols. NO FOOD TREAT POLICY To better limit or prevent exposure to dangerous food allergens there is a no-food-treat policy at Laurel Hill. If you choose, you may send in non-food party favors or crafts to enhance the celebration.

🎁

5

Tuition Information

All tuition deposits and outstanding balances must be submitted prior to the beginning of the school year. Please

remember that automatic monthly tuition will be electronically

deducted from the account families have authorized, on the first of each

month beginning Sept. 1st and continue through May 1st. Accounts with insufficient funds will incur a charge

of $30.00 for processing. NO CASH PAYMENT POLICY

Given the need to limit exposure of our students and staff, parents and

visitors will not be allowed in school buildings and may not be present on

the grounds. Our administrative staff will

therefore be unable to receive cash payments for any type of fees,

including tuition.

2020-2021

Allergy Awareness

Some children in your child’s classroom may have an

allergy to peanuts and tree nuts. We would like to make sure the classroom is peanut/

tree nut free, in order to prevent a life threatening allergic reaction. We are asking for your help to

provide our children with a safe school environment.

Any exposure to peanuts and tree nuts might induce a

serious reaction that requires emergency medical treatment. To reduce the chance of this occurring, please do not send

any peanut or tree nut containing products to be eaten in the classroom. If

your child has eaten peanuts or tree nuts before coming to

school, please be sure that your child’s face and hands have been washed before

coming to school.

Potty Training Please store a supply of your child’s diaper changes and

cleansing wipes with the school. Label your supplies. Send in one complete clothing changes (under

and outer clothes) for “emergencies.” Please label each

item of clothing.

Emergency Clothing Please send in a complete change

of clothes (underwear, socks, pants and shirt). Please label all

clothing and enclose in a labeled plastic bag.

6

THE LAUREL HILL SCHOOL 2 Yr Old & 3 Yr Old Orientation 2020

The$LHS$Toddler,$Three$and$Four$Year$Old$Orientation$sessions$have$been$adjusted$to$meet$the$challenges$presented$by$our$current$circumstances.$$We$have$added$additional$days$of$

orientation$so$as$to$prevent$crowding,$and$observe$social$distancing$guidelines$while$still$maximizing$the$effectiveness$of$each$child’s$orientation$experience.$$$

$Toddlers(and(3,year,olds(Orientation(Schedule($

Orientation$for$toddlers$and$3FyearFolds$will$take$place$on$September$1st,$2nd,$3rd,$4th,$8th,$and$9th.$Each(child(will(participate(in(at(least(three(orientation(visits.$The$first$visit$will$take$place$with$a$parent$present.$Subsequent$visits$will$take$place$in$groups$of$3F4$children,$

without$parents$present.$This$process$supports$children’s$need$to$acclimate$to$the$classroom$environment$while$minimizing$separation$anxiety.$$

The(first(full(day(of(school(will(be(Thursday,(September(10th.(($Your(child’s(teacher(will(email(you(an(invitation(indicating(your(child’s(room(assignment(and(orientation(date(and((time(slot.(

$$

Preschool Orientation Schedule 2020 Toddler (2 year old) and Three Year Old Programs

Room # Tues. Sept.1st

Wed. Sept.2nd

Thurs. Sept. 3rd

Fri. Sept. 4th

Tues. Sept. 8th

Wed. Sept. 9th

2, 6, 9 With Parents 45 min.

With Parents 45 min.

Without Parents 45 min.


Without Parents 3 hrs.


10B With Parents 45 min.






11, 21 With Parents 45 min.






THE LAUREL HILL SCHOOL EMERGENCY CONTACT INFORMATION

Please complete this form and return to LHS immediately. Thank you for your prompt attention to this very important matter.

Child’s Name:_________________________________________________ Gr./Program:______________________

Child’s Home Phone:____________________________________________________________

Parent #1 Name: ____________________________________________________________

Parent #1 Business Phone:________________________________________________________

Parent #1 Cell Phone:____________________________________________________________

Parent #2 Name:______________________________________________________________

Parent #2 Business Phone:________________________________________________________

Parent #3 Cell Phone:____________________________________________________________

Preferred Email Address Email will be the primary form of written communication utilized by Laurel Hill. Please provide us with the email address you would prefer that we use.

Preferred Email Address_________________________________________________________

Emergency Contact Information

Emergency Contact Name: _________________________ Phone #:______________________ Emergency Cell Phone #:_________________________________________________________ Emergency Contact Email:________________________________________________________

It is imperative you fill in & sign the Medical Release form below. MEDICAL EMERGENCY RELEASE FORM

RELEASE In case of emergency, accident, or serious illness to the student named on this form in which medical treatment is required, I (parent/guardian) request the school to contact me. If the school is unable to reach me, my signature below authorizes the school to exercise their own judgment in contacting the physician indicated below and to follow his/her instructions. If this physician is unavailable, the school may make whatever arrangements are necessary or transport the student to a hospital emergency room.

Parent/Guardian Signature__________________________________________________ __________________ DATE SIGNED Does this student have any major or unusual health conditions? YES NO If yes, please specify.____________________________________________________________________________

Allergies:___________________________________________Other Conditions:___________________________

Local Physician’s Name:_______________________________Phone____________________________________

7

2019-2020 GRADES K-5

OCFS-LDSS-4433 (Rev. 06/2019) NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES CHILD IN CARE MEDICAL STATEMENT

To Be Completed By Licensed Physician, Physician Assistant or Nurse Practitioner Name of Child: Date of Birth:

/ / Date of Examination:

/ /

Immunizations required for entry into day care Medical Exemption The physical condition of the named child is such that one or more of the immunizations would endanger life or health. Attach certification specifying the exempt immunization(s).

Yes No

Diphtheria, Tetanus and Pertussis (DPT) Diphtheria and Tetanus and acellular Pertussis (DTaP)

1st Date / /

2nd Date / /

3rd Date / /

4th Date / /

5th Date / /

Polio (IPV or OPV) 1st Date

/ / 2nd Date

/ / 3rd Date

/ / 4th Date

/ /

Haemophilus influenzae type B (Hib)

1st Date / /

2nd Date / /

3rd Date / /

4th Date OR 1st Date (if given on or after 15 months of age)

/ / Pnuemococcal Conjugate (PCV) for those born on or after 1/1/08)

1st Date / /

2nd Date / /

3rd Date / /

4th Date / /

Hepatitis B 1st Date

/ / 2nd Date

/ / 3rd Date

/ / Measles, Mumps and Rubella (MMR)

1st Date / /

2nd Date / /

Varicella (also known as Chicken Pox)

1st Date / /

2nd Date / /

Other Immunizations may include the recommended vaccines of Rotavirus, Influenza and Hepatitis A

Type of Immunization: Date: / /






Tests Tuberculin Test Date: / / Mantoux Results: Positive Negative mm TB Tests are at the physician’s discretion. Acceptable tests include Mantoux or other federally approved test. If positive, or if x-ray ordered, attach physician’s statement documenting treatment and follow-up.

Lead Screening Date: / / Attach lead level statement Lead Screening (Include All Dates and Results)

1 year / / Result: mcg/dL Venous Capillary

2 years / / Result: mcg/dL Venous Capillary Most recent date of lead screening (if different from above):

/ / Result: mcg/dL Venous Capillary

Per NYS law, a blood lead test is required at 1 and 2 years of age and whenever risk of lead poisoning is likely. If the child has not been tested for lead, the day care provider may not exclude the child from child day care, but must give the parent information on lead poisoning and prevention, and refer the parent to their health care provider or the county health department for a lead blood screening test.

(Continued on reverse side)

The Laurel Hill School

OCFS-LDSS-4433 (Rev. 06/2019)

CHILD IN CARE MEDICAL STATEMENT (continued)

Health Specifics Comments

Are there allergies? (Specify) Yes No

Is medication regularly taken? (Specify drug and condition) Yes No

Is a special diet required? (Specify diet and condition)

Yes No

Are there any hearing, visual or dental conditions requiring special attention?

Yes No

Are there any medical or developmental conditions requiring special attention?

Yes No

Summary of Physical Exam Include special recommendations to child day care providers

On the basis of my findings as indicated above and on my knowledge of the named child, I find that: he/she is free from contagious and communicable disease and is able to participate in child day care.

Yes No

Signature of Examiner Address

Please Print Name City, State, Zip

(

)

-

/

/

Title Phone Date

8

IMPORTANT MEDICAL INFORMATION FROM THE HEALTH OFFICE

Dear Parents,

Welcome to The Laurel Hill School. We are looking forward to meeting you, and your little one. Please be assured that the health and safety of your children is our highest priority. Included in this packet you will find required health documents as well as an overview of our health protocols. Please take a moment to familiarize yourself with this important information.

Documentation of Immunization: All children two months and older must show

proof of compliance with the immunization requirements in Public Health Law 2164. Immunization forms need to be signed by a New York State certified physician. Immunization records must be on file in the health office PRIOR TO ATTENDANCE.

Medications at School: In order for the school staff to administer medication to your child the enclosed form must be completed and signed by both the physician and the parent. This includes any over the counter medications. Feel free to call the Health Office with any questions about this protocol. PLEASE NOTE WE WILL NOT ADMINISTER MEDICATION WITHOUT THIS FORM COMPLETED AND SIGNED BY THE PHYSICIAN AND THE PARENT. Children who require an Epi-pen or Benadryl on hand must provide the medical office with these items at the beginning of the school year, along with a “Medications In School” form.

Please be sure to inform us of any health issues and concerns your child might have on an ongoing basis.

Attendance: Many times it is difficult to decide when to keep your child home due to possible illness. Here are some guidelines to follow that are in compliance with The Laurel Hill School Protocol.Parents will administer Daily Health Screenings. Please REFER TO NEW PROTOCOLS FOR 2020) for complete details. We ask that all parents follow these infection control guidelines when their child is sick to minimize the sharing of germs..

Children should not be brought to school if: (REFER TO NEW PROTOCOLS FOR 2020)

- Fever: In general, the child should be fever free (without the use of Tylenol or Ibuprofen) for 24 hours before returning to childcare.

- Conjunctivitis: Your child may return 24 hours after medical treatment has begun and the drainage has stopped.

- Diarrhea and vomiting: Children should remain at home until there have been no episodes for 24 hours.

We thank you for your careful consideration and adherence to these guidelines. For additional information, any question or concerns, please feel free to call the health office.

LHS Nurse DIRECT PHONE: 631-771-1299

IMPORTANT NOTE: Please notify school officials immediately concerning changes to any information

GENERAL PICK-UP AUTHORIZATION

DATE ________________________________________________

CHILD’S NAME __________________________________________________________

CAREGIVER _____________________________________________________________

THE PERSON NAMED BELOW WILL BE PICKING UP MY CHILD ON A REGULAR BASIS.

NAME ___________________________________________________________________________________

ADRESS _________________________________________________________________________________

________________________ _______________________ ________________________ Home phone Cell phone Business phone

RELATIONSHIP TO YOU__________________________________________________________________

DRIVER’S LICENSE NUMBER: __________________________ STATE__________________________

DESCRIPTION: ___________________________________________________________________________

__________________________________________________________________________________________

Please note that this form must be completed before child is released. A verbal consent will NOT suffice. LHS holds no responsibility for child after leaving the campus.

___________________________________________________ _______________________ Parent / Guardian Signature Date

9

AUTHORIZATION FOR CHANGE IN PICK-UP ARRANGEMENTS FOR TODAY

DATE ________________________________________________

CHILD’S NAME __________________________________________________________

CAREGIVER _____________________________________________________________

THE PERSON NAMED BELOW WILL BE PICKING UP MY CHILD.

NAME ______________________________________________________________________

ADRESS ____________________________________________________________________

________________________ _______________________ ________________________ Home phone Cell phone Business phone

RELATIONSHIP TO YOU___________________________________________________________

________________________________________________________________________

DRIVER’S LICENSE NUMBER ____________________ STATE______________

DESCRIPTION: ______________________________________________________________

______________________________________________________________________________

Please note that this form must be completed before child is released. A verbal consent will NOT suffice. LHS holds no responsibility for child after leaving the campus.

___________________________________________________ _______________________ Parent / Guardian Signature Date

THE LAUREL HILL SCHOOL INFANT/TODDLER PROGRAMS

Feeding Schedule and Parent Agreement

• All bottles, cups and utensils must be labeled with the child’s full name. • Powdered formula and sterilized water, ready to feed milk, juice and breast milk must

be pre-measured and labeled with the child’s full name and expiration date. • Children 6 months of age and under must be held during all bottle feedings. • Microwave heating of food and formula is prohibited by regulation. • The provider will make every effort to accommodate the needs of a breast-fed child.

Child’s Name___________________ Date of Birth_______ Parent’s Name____________________________________ Please Initial: ___ I will provide all formula, solid food, water and juice for my child. ___ I give the provider permission to add sterilized water to powdered formula. ___ I give the provider permission to warm milk/formula bottles in a bottle warmer. My child is eating (check all that apply): ! Breast milk ! Formula (Brand)_________________ ! Solid Foods ! Snacks List any food allergies____________________________________ Please feed my child according to the following schedule: Parent’s Signature_______________________Date________ Provider’s Signature______________________Date________

2020-2021


NAPPING AGREEMENT

I understand and consent to the following sleeping arrangements concerning infants and toddlers enrolled at The Laurel Hill School: Infants 6 months to 18 months will nap in cribs in their own classroom. Toddlers 18 months to 24 months and up will nap on cots in their own classroom. All children will be supervised continuously by the classroom staff by both sight and sound. Sleeping children are checked individually and in close proximity throughout the nap time period.

Child’s Name________________________Age_____years___months Child’s Date of Birth_______________________________________ ______________________________________________________

Name of Parent or Guardian

Signature of Parent or Guardian

__________________________________________________ Date

The Laurel Hill School Infant /Toddler Program

Personal History Form

Child’s Name ____________________________ M / F Nick name ___________ Birth date__________________Parent / Guardian ________________________ Home phone ________________

Cell #:_______________________ Business #: __________________________

Email address _________________________________________________________

The Personal History form will assist us to get to know your child’s needs and will assure a smooth transition to The Laurel Hill School Infant Program. Please complete this form prior to your scheduled personal orientation session. This data is for teacher use and is held in complete confidence. This form must be updated every two months.

PERSONAL HISTORY

Adults in household __________Relationship: Mother Father Grandparent(s) Other

___________________

Marital status : Married Separated Divorced Widowed

If divorced, who has legal custody? _____________________________________________

May the non-custodial parent pick up child? Yes No

(LHS must be provided with court-issued custody papers that clearly describe the custody arrangements. Any person

granted custody in such papers may pick up the child during the times that person has custody, and may designate

other persons who are authorized to pick up the child at such times, unless court papers state otherwise.)

Who is responsible for child if parents work outside the home? _____________________

Relation to child _____________________________________________________________

Language(s) spoken at home ______________________ __________________________

_________________________

List the name(s) and age(s) of brothers /sisters and / or other children in the family.

Name _______________________ Age _______

Name________________________ Age _______

Name _______________________ Age _______

Pet(s) Yes ___ No ___ Name(s) _________________________________________

Type(s) ___________________________

Previous experience away from home : None Babysitter

Other___________________________________________________________________

Has your child attended daycare before? Yes No If yes, how long? ______

Place ____________________________________________________________________

Reason for leaving

___________________________________________________________________________

__________________________________________________________________________________________

____________________________________________________________

SOCIAL INTERACTIONS

Nature of your child: Friendly Shy Aggressive Withdrawn

Other __________________________________________________________________

What is your child’s behavior like within his/her peer group? Outgoing Withdrawn

Typical Other _______________________________________________________

How would you best describe your child’s relationship to adults? Shy Outgoing

Cries easily Eager to please

other _____________________________________________________________________________

What type of activities does your child most enjoy? Quiet Noisy Physical

Artistic Other________________________________________________________

Preference: By himself / herself With other children With adults

Other ___________________________________________________________________

MEAL TIME

Does your child have any food allergies or specific dislikes to food(s)? Yes No

If Yes what? _____________________________________________________________

What are his / her favorite foods?

________________________________________________________________________

How often does child eat? Please state mealtime routine

___________________________________________________________________________

How would you describe your child’s eating habits? Picky eater Non-picky eater

Other _________________________________

Does he / she drink from: bottle sippy cup both

Child uses spoon : Yes No

SLEEP TIMEHow often does your child take a nap?

___________________________________________________________________________

How do you get him/her to nap? Holding / rocking Lay down in crib

Other __________________________________________________________________

How long does he / she nap? _____________Disposition on waking . Please state

___________________________________________________________________________

Does your child use a pacifier or comfy blanket / toy Yes No

If yes , specify ______________________________________________________________

Is there a certain routine we should follow to make naptime as pleasant as it can be?

___________________________________________________________________________

HEALTH : PHYSICAL & EMOTIONAL DEVELOPMENTHistory of health concerns or illness? Yes No

If yes, specify _____________________________________________________________

Does your child have any allergies? Yes No

If yes, explain _____________________________________________________________

Is your child receiving any medication on a regular basis at present? Yes No

If yes, specify _____________________________________________________________

Does your child have any speech, vision (wears glasses), hearing difficulties? Yes No

If yes, specify _____________________________________________________________

Age child began sitting _______________ crawling ______________ walking______ talking

______________

Situations that disturb and/or frighten your child: Noise Darkness Strangers Being left alone Lightning

Animals

Other ___________________________________________________________________________

Do you suspect your child has any learning disabilities? Yes No

If yes, specify _____________________________________________________________

Are you as parents anxious regarding your child’s adjustment to school? Yes No

If yes, please comment______________________________________________________

______________________________________________________________________________________

________________________________________________________________

Instructions for teachers if your child falls ill __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________EXPECTATIONSCan LHS take video’s or pictures on special occasions Yes No

What would you like your child to gain from The Laurel Hill School?

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

What areas do you feel are most important in his / her development?

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Please note any other information you feel will be helpful in regard to your child’s adjustment:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

This personal history form has been filled to the best of my knowledge.

Parent / Guardian - Print Name: ______________________________________________

Parent / Guardian - Signature ______________________________________________:

Date_____________________________

OCFS-LDSS-0792 (08/2019) FRONT

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

DAY CARE ENROLLMENTPROGRAM NAME: ADDRESS: PHONE NUMBER:

( ) - CHILD’S FULL NAME: PREFERRED NAME/NICKNAME:

DATE OF BIRTH: / /

GENDER:

CHILD’S HOME ADDRESS:

NAME OF PERSON ENROLLING CHILD: RELATIONSHIP TO CHILD:

Parent Guardian Caretaker Relative Other

PHONE NUMBER(S) OF PERSON ENROLLING CHILD: ( ) - ok to text EMA I L A D D R ESS:

ADDRESS OF PERSON ENROLLING CHILD (IF DIFFERENT THAN CHILD):

EMERGENCY CONTACT NAMES / ADDRESSES Authorized to Pick Up Child PRIMARY PHONE NUMBER OTHER PHONE NUMBER / EMAIL

PRIMARY CONTACT: Yes No ( ) -

ok to text ( ) -

ok to text

Yes No ( ) - ok to text

( ) - ok to text

EMER

GEN

CY

INFO

Yes No ( ) - ok to text

( ) - ok to text

F OR PROGRAM USE ONL Y DATE OF ENROLLMENT: / /

F OR PROGRAM USE ONL Y DATE OF DISENROLLMENT: / /

OCFS-LDSS-0792 (08/2019) REVERSE

CHILD’S FULL NAME: DATE OF BIRTH: / /

Check boxes below to indicate if your child has any special needs/services: None

Early Intervention/Special Education Occupational Therapy Speech/Language Physical Therapy

Allergies (Please list)

Other

Please provide information here AND discuss with your child care provider: CHILD’S PRIMARY CARE PHYSICIAN’S NAME/ GROUP: PHONE NUMBER:

( ) - PREFERRED HOSPITAL: PHONE NUMBER:

( ) - CHILD’S DENTAL CARE: PHONE NUMBER:

( ) -

Child health care information is available by calling toll-free 1-800-698-4543 or the NYS Health Marketplace website: https://nystateofhealth.ny.gov/

AGREEMENTS ● I consent to emergency medical treatment for my child……………………………………………………………………………. ● I consent for my child to take part in neighborhood trips (i.e., library, park and playground) away from the program

under proper supervision………………………………………………………………………………………………………………. ● I understand the program may need additional permissions for situations such as transportation, medication,

release of information, and field trips.…………………………………………………………………………………………………. ● I provided information on my child’s special needs to the program to assist in caring for my child…………………………… ● I understand the program must give parents, at the time of enrollment of a child, a written policy statement as

required by regulation………………………………………………………………………………………………………………….. ● I agree to review and update this information whenever a change occurs and at least once every year…………………….

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No SIGNATURE – PARENT OR PERSON(S) LEGALLY RESPONSIBLE: DATE:

/ /

PHOTO OF CHILD (Optional)

THE LAUREL HILL SCHOOL

OCFS-LDSS-7002 (5/2015) FRONT


MEDICATION CONSENT FORM CHILD DAY CARE PROGRAMS

• This form may be used to meet the consent requirements for the administration of the following: prescriptionmedications, oral over-the-counter medications, medicated patches, and eye, ear, or nasal drops or sprays.

• Only those staff certified to administer medications to day care children are permitted to do so.• One form must be completed for each medication. Multiple medications cannot be listed on one form.• Consent forms must be reauthorized at least once every six months for children under 5 years of age and at least once

every 12 months for children 5 years of age and older.

LICENSED AUTHORIZED PRESCRIBER COMPLETE THIS SECTION (#1 - #18) AND AS NEEDED (#33 - 35). 1. Child’s First and Last Name: 2. Date of Birth:

/ /3. Child’s Known Allergies:

4. Name of Medication (including strength): 5. Amount/Dosage to be Given: 6. Route of Administration:

7A. Frequency to be administered:

OR

7B. Identify the symptoms that will necessitate administration of medication: (signs and symptoms must be observable and, when possible, measurable parameters):

8A. Possible side effects: See package insert for complete list of possible side effects (parent must supply)

AND/OR

8B: Additional side effects:

9. What action should the child care provider take if side effects are noted: Contact parent Contact health care provider at phone number provided below Other (describe):

10A. Special instructions: See package insert for complete list of special instructions (parent must supply)

AND/OR

10B. Additional special instructions: (Include any concerns related to possible interactions with other medication the child is receiving or concerns regarding the use of the medication as it relates to the child’s age, allergies or any pre-existing conditions. Also describe situation's when medication should not be administered.)

11. Reason for medication (unless confidential by law):

12. Does the above named child have a chronic physical, developmental, behavioral or emotional condition expected to last 12 monthsor more and requires health and related services of a type or amount beyond that required by children generally?

No Yes If you checked yes, complete (#33 and #35) on the back of this form.

13. Are the instructions on this consent form a change in a previous medication order as it relates to the dose, time or frequency themedication is to be administered?

No Yes If you checked yes, complete (#34 -#35) on the back of this form.

14. Date Health Care Provider Authorized:/ /

15. Date to be Discontinued or Length of Time in Days to be Given:/ /

16. Licensed Authorized Prescriber’s Name (please print): 17. Licensed Authorized Prescriber’s Telephone Number:

18. Licensed Authorized Prescriber’s Signature:X


OCFS-LDSS-7002 (5/2015) REVERSE


MEDICATION CONSENT FORM CHILD DAY CARE PROGRAMS

PARENT COMPLETE THIS SECTION (#19 - #23) 19. If Section #7A is completed, do the instructions indicate a specific time to administer the medication? (For example, did the licensedauthorized prescriber write 12pm?) Yes N/A No

Write the specific time(s) the child day care program is to administer the medication (i.e.: 12 pm):

20. I, parent, authorize the day care program to administer the medication, as specified on the front of this form, to (child’s name):

21. Parent’s Name (please print): 22. Date Authorized:/ /

23. Parent’s Signature:X

CHILD DAY CARE PROGRAM COMPLETE THIS SECTION (#24 - #30)24. Program Name: 25. Facility ID Number: 26. Program Telephone Number:

27. I have verified that (#1 - #23) and if applicable,(#33 - #36) are complete. My signature indicates that all information needed to givethis medication has been given to the day care program.28. Staff’s Name (please print): 29. Date Received from Parent:

/ /30. Staff Signature:

X

ONLY COMPLETE THIS SECTION (#31 - #32) IF THE PARENT REQUESTS TO DISCONTINUE THE MEDICATION PRIOR TO THE DATE INDICATED IN (#15) 31. I, parent, request that the medication indicated on this consent form be discontinued on / /

(Date) Once the medication has been discontinued, I understand that if my child requires this medication in the future, a new written medication consent form must be completed. 32. Parent Signature:

X

LICENSED AUTHORIZED PRESCRIBER TO COMPLETE, AS NEEDED (#33 - #35) 33. Describe any additional training, procedures or competencies the day care program staff will need to care for this child.

34. Since there may be instances where the pharmacy will not fill a new prescription for changes in a prescription related to dose, time orfrequency until the medication from the previous prescription is completely used, please indicate the date you are ordering the change inthe administration of the prescription to take place.DATE: / /

By completing this section, the day care program will follow the written instruction on this form and not follow the pharmacy label until the new prescription has been filled. 35. Licensed Authorized Prescriber’s Signature:

X



PARENT CONSENT CHANGE ORDER ~ DIAPERING/FEEDING

( ) Change In Feeding Instructions___________________________________ ( ) Change In Diapering Instructions _____________________________________________________________

( ) I hereby give permission to The Laurel Hill School to apply sunscreen and baby ointment (provided by parent).

Child’s Name________________________Age_____years___months Child’s Date of Birth_______________________________________ ______________________________________________________

Name of Parent or Guardian

Signature of Parent or Guardian

__________________________________________________ Date

OCFS-6010 (5/2015) NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES NON-MEDICATION CONSENT FORM

Child Day Care Programs

• This form may be used when a parent consents to having over-the-counter products administered to their child in achild day care program. These products include, but are not limited to: topical ointments, lotions and creams, sprays,sunscreen products and topically applied insect repellant.

• This form should NOT be used to meet the consent requirements for the administration of the following: prescriptionmedications, oral over-the-counter medications, medicated patches, and eye, ear, or nasal drops or sprays. OCFSForm 7002 would meet the consent requirements for medications.

• One form must be completed for each over-the-counter product. Multiple products cannot be listed on one form.• This form must be completed in a language in which the staff is literate.• If parent’s instructions differ from the instructions on the product’s packaging, permission must be received from a

health care provider or licensed authorized prescriber.

PARENT TO COMPLETE THIS SECTION (#1 - #14) 1. Child’s first and last name: 2. Date of birth: 3. Child’s known allergies:

4. Name of product (including strength): 5. Amount to be administered: 6. Route of administration:

7A. Frequency to be administered, include times of day if appropriate: OR 7B. Identify the conditions that will necessitate administration of the product (signs and symptoms must be observable prior to administration):

8A. Possible side effects: See product label for complete list of possible side effects (parent must supply) AND/OR

8B: Additional side effects:

9. What action should the child care provider take if side effects are noted:Contact parent

Other (describe):

10A. Special instructions: See package insert for complete list of special instructions (parent must supply) AND/OR

10B. Additional special instructions:

11. Reason(s) for use (unless confidential by law):

12. Parent name (please print): 13. Date authorized:

14. Parent signature:

X

DAY CARE PROGRAM TO COMPLETE THIS SECTION (#15 - #21) 15. Program name: 16. Facility ID number: 17. Program telephone number:

18. I have verified that #1, -#14 are complete. My signature indicates that all information needed to administer this product has been givento the child day care program.19. Staff’s name (please print): 20. Date received from parent:

21. Staff’s signature:

X


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