New Preschool Registration packet 2019-2020

Montessori Pre-K

Where Creating+Learning=FUN! At Discovery Kidzone we are blessed to have an amazing staff and highly qualified, loving

teachers. We are a Christian Montessori inspired preschool. We use a combination of Montessori, Reggio Emilia and a hands on, theme based curriculum. While at Discovery Kidzone your child will be challenged to become independent, intellectual, creative and social as we believe in developing the whole child. Throughout the year we will work with you to help nurture and teach your child. When your child is developmentally ready to learn a new skill we will create a plan together. We believe that curiosity breeds discovery and we encourage it in any way.

Discovery Kidzone is part of the Stars to Quality program for the state of Montana and with that we have continuing education for the entire staff and constant quality control to ensure a High Quality learning environment. We proudly accept best beginning and Child Care Aware scholarships, please contact me for more information regarding how to apply with a scholarship.

These are the classes we are enrolling for: Young 3's (2 1/2-3 1/2 and potty trained), Older 3's (3 1/2-4), Part time Pre-K (4-5), Full time pre-k (4-5), Kindergarten (5,6)

We also have the option to phase in the pre-k class as well with our afternoon enrichments classes. Your child’s education is as important to us as it is to you. Not only will we customize the program to each student’s specific learning style, but we will also teach an advanced, age appropriate, Christian curriculum. Our preschool and kindergarten experience will be one they will never forget. We will continue to have music classes, Mad science, Spanish, Ski lessons and PE. At Discovery Kidzone we pride ourselves on academic achievement as well as expression of all the arts. We believe that children have unique learning styles and we will encourage cognitive growth in the most natural way for each student.

We offer all meals for your child, prepared on site by our own chef or you have the option to pack your child a lunch. This year we divided the two months with the 5th week across all the other months to make a consistent monthly tuition. We increased our rates to pay our teachers more and continue offering benefits. Our prices are subject to a tuition increase if needed to cover cost of care. If an increase is needed we will give parents a notice 30 days in advance

We are always working to improve our program and strive for the best in quality and education. Feel free to offer suggestions and help anytime. Don’t ever hesitate to email me, call me or stop into my office. We have new exciting things planned for this year and I can’t wait to see what God has in store for us.

Rachel Supalla, Executive DirectorSarah Roddewig, Assistant Director DKZ 2Amber Chiles, Director DKZ 3

State of Montana

Department of Public Health and Human Services

Quality Assurance Division – Licensure Bureau

Child Care Licensing

– SEE REVERSE SIDE –

DPHHS-QAD/CCL-113 (Revision 7-2006)

EMERGENCY CONTACT AND PARENTAL CONSENT

THIS FORM MUST BE TAKEN WITH THE CHILD WHEN EMERGENCY MEDICAL CARE IS NEEDED.

Child’s Name: Birth Date:

Address:

Mother / Legal Guardian’s Name: Home Number:

Address: Cell Number:

Work Address: Work Number:

Email Address:

Father / Legal Guardian’s Name: Home Number:

Address: Cell Number:

Work Address: Work Number:

Email Address:

Emergency Contact Person: Contact Number:

Emergency Contact Person: Contact Number:

Physician / Medical Care Source: Contact Number:

Health Insurance Carrier & Policy Number:

Persons authorized to pick up child:

Name: Name:

Name: Name:

WRITTEN CONSENT IS GIVEN FOR:

□ Yes □ No EMERGENCY MEDICAL CARE

□ ADMINISTRATION OF PRESCRIPTION MEDICATIONS Medication Authorization form and Medication Administration Log

Must be completed

□ ADMINISTRATION OF NON-PRESCRIPTION MEDICATIONS OTC Medication Authorization Form and Medication Administration

Log must be completed

□ ADMINISTRATION OF SPECIAL DENTAL OR DIETARY NEEDS:

Please Specify:

□ TRIPS: □ Yes □ No TRANSPORTATION BY THE FACILITY FOR TRIPS

□ Yes □ No DAILY TRANSPORTATION PROVIDED BY THE FACILITY (Facility Has the Option to Offer)

IF YOUR CHILD IS TRANSPORTED BY THE FACILITY, ARE THERE ANY INSTRUCTIONS FOR SPECIAL CARE FOR THE CHILD (I.E. MOTION SICKNESS, SEIZURES, ETC.) DURING TRANSPORTATION?

HEALTH HISTORY

YES NO YES NO

Hay fever, asthma, or wheezing □ □ Chickenpox □ □ Eczema or frequent skin rashes □ □ Diabetes □ □ Convulsions/Seizures □ □

Trouble with passing urine / bowel movement □ □

Heart condition □ □ Frequent colds, sore throats, earaches, tonsillitis, pneumonia □ □

YES NO

Allergies or reaction: (food or other) □ □Please Explain:

YES NO

Other Health Concerns (special disabilities): □ □

Please Explain:

SIGNATURE OF PARENT OR GUARDIAN DATE

DPHHS-QAD/CCL-120 (Revision 06-07)

NON-INGESTIBLE OVER THE COUNTER (OTC) MEDICATION

AUTHORIZATION FORM

TO BE COMPLETED BY PARENT

Child’s Name______________________________________________________Date of Birth_____/____/___

Program Name____________________________________________________Today’s Date_____/____/___

*************************************************************************************************

I give permission for the administration of following non-ingestible over the counter medications (mark all that

apply):

Diaper Rash Cream/Ointments

Insect Repellent

Sunscreen

Cortisone/Anti-Itch Creams/Ointments

Medicated Lip Treatments

OTC Antibiotic Creams/Ointments

Burn Creams/Sprays

Other Non-Ingestible OTC’s: (Please Specify)______________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

To administer a non-ingestible over the counter (OTC) medication:

The OTC medication must be brought to the day care facility from the parent;

The OTC medication must be in its original container, with a legible label, and expiration date of medication;

The child’s name must be on the original container

Special handling/storage Instructions____________________________________________________Refrigeration Y/N

Parent/Guardian Signature (required)__________________________________________________________________

* This document must be updated on an annual basis.

Unused Medication: Returned to Parent Y/N or Discarded Appropriately (circle one)

By: ________________________________________________ Date _____/_______/_______

*Keep in the child’s file when medication is finished.

Health and Illness Policy

At Discovery Kidzone we understand that children will have stuffy noses and coughs at times. We do ask

however, that if your child exhibits any of the following symptoms, please keep them at home. This is the best

way to keep the staff healthy to care for your child and keep other children from getting sick. Parents agree to

keep (or take) their child/children at home or seek alternate care arrangements as soon as possible within

45 min of being called by provider. You will be charged the late fee if you arrive later than 45 min after being called. Please help us keep the sicknesses away at Discovery Kidzone! Your child must stay home from

school until 24 hours after being symptom free if they need to be picked up for the following conditions:

Fever (101.1 °f or higher) – child needs to be fever free for 24 hours without the aid of medication

Diarrhea – (3 contained or 2 out of clothes) child must be symptom free for 24 hour without the aid of

medication

Vomiting – child must be symptom free for 24 hours without the aid of medication (If your child was vomitingthe night before please do not bring them to school!)

Runny nose with colored discharge –Green/Yellow mucous from Nose Rash – Any rash suspicious of being contagious (red or white bumps, rash that is new or not typical, anything

that follows a low grade fever) Discharge from eyes or ears

Lice – child needs to be treated and nits removed before return

Communicable Diseases - hand foot and mouth, chicken pox, measles, mumps, conjunctivitis, influenza. Ring Worm

Impetigo

Strep Throat

Severe cough (croupy or whooping sound) Productive cough (gagging/raising phlegm) Difficulty Breathing or Any condition-preventing child from participating comfortably in usual activities Requiring one on one care/ Lethargic

Medication:

If your child is on antibiotics he/she continues to be contagious for 24 hours after the first dose of medicationand

can not return to childcare until this time period has passed.

Please keep a copy of this form as a reference.

By signing below, I accept and agree to the health and illness policy at Discovery Kidzone Preschool.

By Parent/Guardian: ____________________ Date: __________________

Director, Rachel Supalla

Montana City, MT 59634

Prepared by Rachel Supalla 2014. Updated 2015. Updated 2016. Updated 2017. Updated Jan 2018, updated Jan 2019

Child imMTrax Permission Form

Childs Name:____________________________________________________ Sex: M__ F__ Date of Birth:___________

I authorize my health care provider and a public health agency to collect and enter my child’s immunization

records into the Department of Public Health and Human Services’ Immunization Information System (IIS).

The IIS is a confidential, computer system that contains immunization records. I understand that information in

the registry may be released to a public health agency as well as my health care providers to assist in my

child’s medical care and treatment. In addition, information may be released to child care facilities and schools

in which my child is enrolled to comply with state immunization requirements. I understand that I can revoke

this authorization and have my record removed at any time by contacting my local health department.

Client/Parent/

Guardian Signature:____________________________________________________ Date:____________________

Primary Health Care Provider: ___________________________________________

Please Print

IZ Consent –101 (10/05/2012)

Child imMTrax Permission Form

Childs Name:____________________________________________________ Sex: M__ F__ Date of Birth:___________

I authorize my health care provider and a public health agency to collect and enter my child’s immunization

records into the Department of Public Health and Human Services’ Immunization Information System (IIS).

The IIS is a confidential, computer system that contains immunization records. I understand that information in

the registry may be released to a public health agency as well as my health care providers to assist in my

child’s medical care and treatment. In addition, information may be released to child care facilities and schools

in which my child is enrolled to comply with state immunization requirements. I understand that I can revoke

this authorization and have my record removed at any time by contacting my local health department.

Client/Parent/

Guardian Signature:____________________________________________________ Date:____________________

Primary Health Care Provider: ___________________________________________

Please Print

IZ Consent –101 (10/05/2012)

THIS AGREEMENT is entered into as of this day of in Location by and between Supalla Inc, DBA Discovery Kidzone

Montessori School Rachel Supalla (hereinafter referred to as "Provider") and _________________________ (hereinafter referred to as

"Parent/Guardian").

This Agreement contains the terms agreed upon between Provider and Parent/Guardian for the care of:

Child ____________________________________________________________ D.O.B. _____________

Child ____________________________________________________________ D.O.B. _____________

1. Registration/holding Fee: Parent/Guardian agrees to pay non refundable registration/holding fee of $125.00 for the first child and 10% discount for the 2nd. Returning students who re-enroll are eligible for a 25.00 discount if they registration is paid by Feb 15th Security/Holding Deposit Paid [ ] YES [ ] NO

Rates : Payment is due and payable the first of every month. If your child is absent from care the normal monthly rate will be due and payable. A 30 day notice is required before the end of contract is ceased, monthly rate will due and payable.

The Monthly rate for 2 half days a week will be $160.00 Full day $325.00 The Monthly rate for 3 half days a week will be $230.00 Full day $440.00 The Monthly rate for 5 half days a week will be $365.00 5 full day $715.00 Daily Rate to add a day 38.00 full day 17.00 half day and 5.00 for lunch bunch for the hour of lunch

Best Beginnings Scholarships: We accept best beginnings scholarships but will not begin care until the scholarship has been

completely approved. You are required to pay the additional amount of tuition due that is not covered by your scholarship. For

Example: If you have a full scholarship that pays us 550.00 a month you will be expected to pay 75.00 a month to maintain

your spot in addition to your co-pay.

4. Sibling Discount: 10% off the 2nd child off the lowest rate.

5. Days and Hours: The parties to this agreement have agreed to the following schedule of care. The school year follow a

traditional school schedule. Monday Tuesday Wednesday Thursday Friday

[ ] 8:45-11:30[ ] 12:15-3:00 Full day preschool is from 8:30-3:00, Full day students have the option to utilize before and after

school from 7:00-8:45 and 3:00-5:30 at no additional cost, half day students must pay extra for extra hours.

6. Late Fees: Parent/Guardian agrees to pay a late fee $2.00 a min for the time that Child remains in care after hoursIf the monthly rate is not paid by the 5th of every month the Parent/Guardian agrees to pay a late fee in until the account is current. The

check bouncing fee is $35.00 and any other fees it may incur. All late fees will be due and payable7. Vacation Credit: A 30 day notice is required to approve up to one week of vacation a year at 50% off your weekly tuitionfull time students. Part time students are allowed 3 days of vacation at 50% off your weekly rate.

8. Tuition Express and Pro Care: In order to insure more quality time with your child we require every parent to be enrolledin our secure and safe automatic billing system through procare tuition express. Tuition is due the 1st of every month however, youmay set up an alternative billing schedule if necessary.

9. Holiday Closings: New Years Eve and day, Martin Luther King Jr., President’s day, Memorial day, Independence dayThanksgiving and the day after, Christmas Eve and Christmas, the Monday after Easter. Two Staff training days. We may need toclose due to inclement weather.10. Referral Credit: Every currently enrolled student is eligible for a $50.00 referral credit for every new student once theyhave paid for their registration and has completed a month of tuition you will receive a credit unlimited you can refer as manystudents as you like.

11. Open Door Policy: At Discovery Kidzone we have an open door policy. This means at any time during the day come, visit,volunteer or spend time with your child. We value you as a parent and know that parent participation is beneficial to your child'sgrowth and development as well as helpful for our program. Please feel free to stop by any time.

12. Meals: We offer hot, nutritious meals daily provided by our on-site chef in Montana City and in Clancy they have the optionof eating at Clancy school or they can bring a packed lunch. To have meals provided is $3.00 a day.

By Parent/Guardian: _________________________________________________________ Date: __________________

Executive Director, Rachel

Supalla

DKZ 2 (406) 443-5833

rachel@kidzonemontessori.comDKZ 3 Director, Amber Chilesamberchiles28@yahoo.comDKZ 3 (406) 465-8646www.kidzonemontessori.com

Montessori Pre-KOur prices are subject to a tuition increase if needed to cover cost of care. If an

increase is needed we will give parents a notice 30 days in advance

2019-2020

updated by Rachel Supalla 2019

Individual Personal-Care Plan for Preschool Children

(Form adapted from Prime Times Second Edition) Child’s Name Date of Birth

What would you like us to call your child?

Developmental History

Hears well? YES NO Comments:

Talks like other children? YES NO

Comments:

Understand child? YES NO

Comments:

Walks, runs, and climbs like others? YES NO

Comments:

Family history of hearing Impairments? YES NO

Comments:

Vision okay? YES NO

Comments:

Recent medical problems? YES NO

Comments:

Other concerns? YES NO Comments:

2 Individual Personal-Care Plan for Preschool Age Children continued

©2008 by Jim Greenman, Anne Stonehouse, and Gigi Schwelkert. May be reproduced for use in a child care program or staff training.

Family Information With whom does child reside?

Who else lives in the home (siblings, extended family, pets)?

What does the child call family members?

Language(s) spoken at home:

Are books read in languages other than English?

Are there words/phrases in home language that we should know?

Are there cultural or family customs, rituals, or traditions that will help us make your child’s experience more meaningful?

Are there other matters or concerns you feel are important?

Health/Development Describe any serious illnesses or hospitalizations:

Describe any special physical conditions, disabilities, or allergies:

Has your child been diagnosed with a special need?

If so, is your child receiving any special services?

Regular medications?

Eating Routine Any food allergies?

Food likes and eating preferences:

Food dislikes or eating problems:

3 Individual Personal-Care Plan for Preschool Age Children continued

©2008 by Jim Greenman, Anne Stonehouse, and Gigi Schwelkert. May be reproduced for use in a child care program or staff training.

Special diet/requests:

Special characteristics or difficulties?

Toilet/Diapering Habits Is your child toilet trained: ☐urination ☐bowels

Does your child use the toilet independently? YES NO

Comments:

Are bowel movements: ☐regular How often:

Is there a problem with: ☐diarrhea ☐constipation

What is used at home: ☐potty chair ☐special seat ☐regular seat

Word used for urination: bowel movement:

Does the child have accidents?

Comforting/Distress Does your child have a security object? Name?

Does your child use a pacifier? When?

Other information?

What comforting objects would you like your child to have at the program?

Sleeping Routine Does child sleep in: ☐bed ☐family bed

Pre-nap routines/rituals:

How many naps per day (typical): AM to PM to

Length of nap:

Waking behavior/routine:

Special concerns:

What time does child go to bed at night: awake in morning:

Are there any sleep time rituals?

4 Individual Personal-Care Plan for Preschool Age Children continued

©2008 by Jim Greenman, Anne Stonehouse, and Gigi Schwelkert. May be reproduced for use in a child care program or staff training.

Separation Has your child been left in the care of someone other than yourself? ☐ Yes ☐ No

If so, with whom?

What difficulty does your child experience separating from you?

What are some ways to calm your child?

What are your feelings about leaving your child in our care?

How can we help you feel more comfortable and involved in the care of your child?

Social Relationships Has your child had any experience playing with other children?

Would you characterize your child as often:

☐ friendly ☐ aggressive ☐ shy ☐ withdrawn

Reaction to strangers?

Have you had any previous child care experience?

If so, did it meet your needs and expectations?

Explain:

Does your child prefer to play: ☐ alone ☐ in small groups

Favorite toys and activities?

Is your child frightened by:

☐ animals ☐ rough children ☐ loud noises ☐ darkened rooms

Explain:

What is your style of guidance and discipline?

Daily Schedule Please describe by approximate time your child’s current daily activities (that is, awakening, eating, napping, toilet habits, fussy time, evening bedtime):

5 Individual Personal-Care Plan for Preschool Age Children continued

©2008 by Jim Greenman, Anne Stonehouse, and Gigi Schwelkert. May be reproduced for use in a child care program or staff training.

Morning

Afternoon

Evening

Parenting Philosophy Do you have ideas about parenting that would help us to better care for your child?

What do you as a family hope to get out of this child care experience?

We will update the personal care plan every 3 - 4months, or sooner if requested by a parent/guardian or as needed by the staff.

Parent Signature Date

Staff Signature Date

Date of change Parent Initials Staff Intials

Date of change Parent Initials Staff Intials

405-443-5833 | Rachel@kidzonemontessori.com | 1 Friendship Ln. Clancy, Mt. 59634 | kidzonemontessori.com

Participant’s Name: Parent’s name:

Phone Number and Email:

Has my permission to participate in field trips and activities at Discovery Kidzone Montessori school run by Supalla Inc, in Jefferson, Broadwater, and Lewis and Clark counties in Montana. I also give permission to attend ski field trips at Great Divide which include trans-portation provided by Discovery Kidzone and parent volunteers.

In consideration of the services of Supalla Inc., Discovery Kidzone, its agents, owners, officers, volunteers, partic-ipants, employees, and all other persons or entities acting in and capacity on their behalf (hereinafter collectively referred to as “DKZ”), I hereby agree to release and discharge DKZ, on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows:

A parent or legal guardian must sign if the participant is under 18 years of age.

ACTIVITIES, RISKS AND ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS: Participating in Discovery Kidzone educational, instructional and recreational camps run by DKZ may include unforeseen risks. These activities can take place inside or outside, they can take place day or night, be located on public, private or com-munity land. May include but not limited to: climbing on natural rocks or boulders, hiking, kayaking, skiing, riding a chair lift, climbing on park and playground equipment, driving and use of any equipment, sports and games, transportation in vehicles, swimming and water activities and fishing, I acknowledge that rock climbing and skiing are dangerous activities, therefore unforeseen risks, hazards and dangers may arise and if anything unforeseen happens DKZ is not responsible. I expressly agree and promise to accept and assume all of the risks existing in these activities, both known and unknown, whether caused or alleged to be caused by the negligent acts or omissions of DKZ. My participation and my child’s partici-pation in these activities are purely voluntary, and I elect to participate in spite of the risks. I agree not to sue or initiate any legal action (whether in court of in arbitration) against DKZ or any present or future officers, directors, shareholders, agents, employees and representatives of DKZ, in connection with any claim which could have been or could be raised against any of them in any way connected with, arising out of, or relating to activities at DKZ or provided thereby, resulting in personal injury, damage or death to the maximum extent permitted by law.

The parent gives permission for the child to participate in these activities.

Parent Signature:

Date:

Program Director Signature:

Discovery Kidzone Field trip and activity permission slip

updated by Rachel Supalla 2019

Photo Release

Provider’s name: Discovery Kidzone Montessori School or Rachel Supalla

Child’s full name: _______________________

Photographs and videos are taken on different occasions such as birthdays, holidays, outings and special

occasions and for educational purposes. We use these pictures/videos in our school for teaching, arts & crafts,

albums and various other things. We upload the pictures to our websites www.kidzonemontessori.com,

www.facebook.com/discoverymontessoriMT.

http://www.facebook.com/DiscoveryMontessoriMT#!/KidzoneTeachermama

http://discoverykidzone.blogspot.com/

Please mark the appropriate box:

□ I give permission

□ I do not give permission to Discovery Kidzone Montessori or Rachel Supalla to take photographs/videos or

have photographs/videos taken of the above named child should the occasion arise.

I understand that these photographs and/or videos will not be sold and will be handled with the utmost care.

By Parent/Guardian: ____________________ Date: __________________

By Rachel Supalla: ____________________ Date: __________________

Executive Director, Rachel Supalla DKZ 2 (406) 443-5833rachel@kidzonemontessori.comDKZ 3 Director, Amber Chilesamberchiles28@yahoo.comDKZ 3 (406) 465-8646 www.kidzonemontessori.com

updated by Rachel Supalla 2019

We are excited to offer the safety, convenience and ease of Tuition Express® – a payment processing system that allows on-time tuition and fee payments to be made from either your bank account or credit card.

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT and CREDIT CARD

I (we) hereby authorize (business name) ____________________________________________ to initiate credit card charges to the below referenced credit card account (Section A) OR, initiate debit entries to my (our) Checking or Savings Account, indicated below (Section B). To properly affect the cancellation of this agreement, I (we) are required to give 10 days written notice. Credit Union Members: Please contact your Credit Union to verify account and routing numbers for auto-matic payments. Check with the center for accepted credit card types.

COMPLETE ONE SECTION ONLY

SECTION A (Credit Card)

_______________________________________________________________________________________________________Cardholder Name Phone #

_______________________________________________________________________________________________________Cardholder Address City State Zip

_______________________________________________________________________________________________________Account Number Expiration Date

_________________________________________________________________________________________________________________________________ Cardholder Signature Date

SECTION B (Bank Account)

_______________________________________________________________________________________________________Your Name Phone #

_______________________________________________________________________________________________________Address City State Zip

_______________________________________________________________________________________________________Bank or Credit Union Name

_______________________________________________________________________________________________________Bank or Credit Union Address City State Zip

_______________________________________________________________________________________________________Routing Transit Number (see sample below) Account Number (see sample below)

Automated Payment Processing Safe – Convenient – Easy

For Official Use Only

Date Received

________________________

Employee Signature

________________________

A service of

Checking Savings

Copyright Procare Software 1132014

SPECIAL NEEDS HEALTH CARE PLAN -To be approved by a Health Care Provider-

Today’s Date

Child’ Full Name Date of Birth

Parent’s/Guardian’s Name Telephone No. ( )

Primary Health Care Provider Telephone No. ( )

Specialty Provider Telephone No. ( )

Specialty Provider Telephone No. ( )

Diagnosis(es)

Allergies

ROUTINE CARE Medication To Be Given

at Child Care Schedule/Dose (When

and How Much?) Route (How?)

Reason Prescribed

Possible Side Effects

List medications given at home:

NEEDED ACCOMMODATION(S) Describe any needed accommodation(s) the child needs in daily activities and why:

Diet or Feeding: _________________________________________________________________________________

Classroom Activities: _____________________________________________________________________________

Naptime/Sleeping: _______________________________________________________________________________

Toileting: _______________________________________________________________________________________

Outdoor or Field Trips: _____________________________________________________________________________

Transportation: ___________________________________________________________________________________

For Behavior Changes: _____________________________________________________________________________

Additional comments: ______________________________________________________________________________

________________________________________________________________________________________________

4/8/2008 1

4/8/2008 2

SPECIAL NEEDS HEALTH CARE PLAN -continued-

SPECIAL EQUIPMENT / MEDICAL SUPPLIES

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

EMERGENCY CARE

CALL PARENTS/GUARDIANS if the following symptoms are present:

__________________________________________________________________________________

__________________________________________________________________________________

CALL 911 (EMERGENCY MEDICAL SERVICES) if the following symptoms are present, as well as contacting the parents/guardians:

__________________________________________________________________________________

__________________________________________________________________________________

TAKE THESE MEASURES while waiting for parents or medical help to arrive:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

SUGGESTED SPECIAL TRAINING FOR STAFF

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Health Care Provider Signature Date

PARENT NOTES (OPTIONAL)

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________ I hereby give consent for my child’s health care provider or specialist to communicate with my child’s child care provider to discuss any of the information contained in this care plan.

Parent/Guardian Signature Date

Important: In order to ensure the health and safety of your child, it is vital that any person involved in the care of your child be aware of the child’s special health needs, medication your child is taking, or needs in case of a health care emergency, and the specific actions to take regarding your child’s special health needs.