For Center Use - Busy Bees Preschool Center



|For Center Use |

|Date of Admission: |

|Age at Admission: |

|Place of birth: |

CHILD INFORMATION

|Child’s Name: (first, middle, and last name) |Cell Phone (mother): |

|Date of Birth: |Cell Phone (father): |

|Home Address: |Place of Birth: |

|Home Phone: |Primary Language: |

Child’s Identifying Information: (Required by DEEC regulations)

|Eye Color: |Height: |

|Hair Color: |Weight: |

|Sex: |Skin Color: |

|Identifying Marks: |Special Health Conditions: |

|ALLERGIES: |MEDICATIONS: |

Parent/Guardian Information

|Mother/Guardian Name: |Father/Guardian Name: |

|Relationship to Child: |Relationship to Child: |

|Home Address: |Home Address: |

|Home Phone: |Home Phone: |

|Cell Phone (mother): |Cell Phone (father): |

|Email address: |Email address: |

|Work Place: |Work Place: |

|Work Phone: |Work Phone: |

|Work schedule: |Work schedule: |

EMERGENCY CONTACTS

(Please provide 2 contacts (other than parent). These contacts must also appear on the Release of Child from Center, page 4.)

|Name: |Name: |

|Address: |Address: |

|Relationship to child: |Relationship to child: |

|Phone: |Phone: |

|Child’s Physician/Clinic: |Phone: |

|Health Insurance and Number: |

|Dentist: |Phone: |

Parent/Guardian Signature:

_______________________________________________________________________Date:________________________

1.

Rev. ‘14

 

CHILD’S NAME: ______________________________________________________ DOB: __________________________

The following permissions remain valid for 1 year after date of signing and will need to be updated annually. You may refuse permission for any of the following. You will be informed orally or in writing for all of the following permissions.

I GIVE PERMISSION TO BUSY BEES PRESCHOOL CENTER, Inc. TO ALLOW MY CHILD _____________________________:

(Please initial each permission.)

________ To be given Acetaminophen, Ibuprophin, Children’s Tylenol for pain or fever over 100 with health care provider’s written permission to be renewed weekly after gaining your permission by phone.

________ To be given 1 tablet or 1 teaspoon of Benadryl with health care provider’s written permission to be renewed weekly after gaining your permission by phone.

________ To have Vaseline applied on the lips or skin for chafing as needed.

________ To have sunscreen UBV and UVA SPF 30 applied twice daily as needed May through August.

________ To have insect repellent containing DEET applied once daily as needed.

________ To participate in cost-free dental, hearing and vision screenings (on site) through Action Health Services (978-878-8523).

________ To go for walks in the neighborhood and to Parkhill Park.

________ To paint fingernails with nail polish as related to curriculum or just for fun.

IN ADDITION, AGREE TO THE FOLLOWING:

(Please initial each permission.)

________ To allow information to be shared (to ease transitions) with relevant staff of Early Intervention, Resource & Referral Agency, _____________________ Public School and my child’s former childcare provider _______________________________ {name).

________ To be included in early childhood practicum studies, observation, or research at the Center.

________ To be photographed or videotaped as related to program activities, and to allow the media (including Busy Bees web site) to reproduce these photos or videos of my child.

________ TO PARTICIPATE IN MY CHILD’S CLASSROOM TWICE ANNUALLY.

________ To pay tuition through authorized bank withdrawal prior to services: WEEKLY, BI-WEEKLY, MONTHLY.

(Circle one.)

________ To have my child attend from ____________a.m. to ______________ p.m. ________________ days a week.

Parent/Guardian Signature:

___________________________________________________________________DATE:__________________________

YEAR 2: ____________________________________________________________ DATE: _________________________

YEAR 3:_____________________________________________________________ DATE: _________________________

2.

Rev. ‘14

 

CHILD’S NAME:________________________________________________________DOB:___________________________________

This sheet and the face sheet of your child’s file will be copied to the FIELD TRIP BINDER, and brought on field trips and off-site activities. Please keep the information current.

Authorization for Emergency Treatment

I give permission to Busy Bees staff, trained in CPR/First Aid to provide treatment in emergency and non-emergency situations.

In the event of an emergency requiring medical attention for my child____________________________, I understand that every effort will be made to contact me. In the event that I cannot be reached, I authorize Busy Bees Preschool Center to transport my child to_______________________________ Hospital (or to the nearest hospital) and to secure the necessary medical treatment.

Signature: ________________________________________________________________________ Date: ______________________

Year #2: __________________________________________________________________________Date:______________________

Year #3: __________________________________________________________________________Date:______________________

Authorization for Release of Child from Center

I authorize the release of my child to the following persons. Add/or delete names as necessary.

Parents/Guardians: ___________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Phone:______________________________________________________________________________________________________

|Name: |Name: |

|Address: |Address: |

|Relationship: |Relationship: |

|Phone: |Phone: |

|Name: |Name: |

|Address: |Address: |

|Relationship: |Relationship: |

|Phone: |Phone: |

|Name: |Name: |

|Address: |Address: |

|Relationship: |Relationship: |

|Phone: |Phone: |

Signature: ______________________________________________________________________Date:________________________

Year #2 ________________________________________________________________________Date:_________________________

Year #3 ________________________________________________________________________Date:_________________________

3.

Rev.’14

CHILD’S NAME:_______________________________________________________DOB: ___________________________________

Please complete this section of personal history and developmental background. Feel free to add more information, if necessary. (Some information that you share in the ESI-R Parent Questionnaire is repeated here.)

PERSONAL HISTORY

Type of birth: Natural _______________________C-section _____________________ Pre-mature ____________________

Induced ____________________________ Other ___________________________

Complications? (Explain.)______________________________________________________________________________________

Age your child began: sitting __________ crawling __________ walking ________1stwords ________ sleeping all night __________

Speech or language difficulties (Explain) __________________________________________________________________________

Serious illnesses or injuries (Explain.) _____________________________________________________________________________

Allergies, special conditions or disabilities (Explain.)_________________________________________________________________

Has your child been referred or received Early Intervention or special education services? (Explain.)_________________________

____________________________________________________________________________________________________________

Does your child present repeating or recurring challenging behaviors? (Explain.)__________________________________________

____________________________________________________________________________________________________________

Child’s position in the family: ___________________________________________________________________________________

Siblings in the family:

|FULL NAME: |FULL NAME: |

|BIRTHDATE: |BIRTHDATE: |

|FULL NAME: |FULL NAME: |

|BIRTHDATE: |BIRTHDATE: |

|FULL NAME: |FULL NAME: |

|BIRTHDATE: |BIRTHDATE: |

10. Child’s primary caretakers and schedules:

|NAME |RELATIONSHIP |DAYS/HOURS |

| | | |

| | | |

| | | |

11. Child’s family lifestyle: Two-parent (traditional) __________Two-parent (non-traditional) __________ Single parent_________

Blended (one family) _________________ Blended (two or more families) ________________ Foster family___________________

Adoptive________________________________________Mixed-adoptive_______________________________________________

12a. Child’s cultural heritage and primary language: _________________________________________________________________

12b. Child’s living arrangements (apartment, house, farm, etc.) _______________________________________________________

4.

Rev. ‘14

Developmental Background continued

CHILD’S NAME: _____________________________________________________________________ DOB:_____________________

Rate your child’s adjustment to the following experiences as EASY (E) or DIFFICULT (D):

Bonding ___________ Transitions/changes ____________ Relating to other children _____________ Toilet___________________

Separation___________ Eating___________ Relating to siblings’ _________ Sleep________ Relating to other adults’___________

Explain. _____________________________________________________________________________________________________

What bathroom words does your child use? _______________________________________________________________________

What time does your child go to bed? ____________________________ Get up in the morning? ____________________________

How many hours a day does your child watch television and/or play on the computer? ____________________________________

Describe your child’s evening and nighttime routine. ________________________________________________________________

____________________________________________________________________________________________________________

Does your child nap or rest during the day? _______For how long? ____________________________ When? __________________

Rate your child’s personality development on a scale of 1 to 10. 1= not at all and 10=very much.

|Enjoys/needs physical activity | |Concentrates easily | |

|Has a long attention span | |Has a strong memory | |

|Is talkative and verbal | |Persists at tasks independently | |

|Learns easily by visual means | |Learns easily by auditory means | |

|Is easily comforted | |Is fearful | |

|Easy-going | |Strong-willed | |

|Seeks help when needed | |Seeks help when not needed | |

Name your child’s favorite:

|Role Model |Food |TV Program |

|People |Activity |Computer Activity |

Name your child’s fears _____________________________________frustrations _________________________________________

How is your child comforted? ___________________________________________________________________________________

Your behavior management or discipline style:

|Removal of toy or activity |Occasional spanking |

|Time-out |Logical/natural consequences |

|Reasoning |Other |

(Describe.)___________________________________________________________________________________________________

What would you like your child to learn from his/her experience here? _________________________________________________

____________________________________________________________________________________________________________

What life events (if any) has your child experienced or is experiencing, which you suspect may impact growth and/or development? _______________________________________________________________________________________________

____________________________________________________________________________________________________________

What else would you like us to know about your child? ______________________________________________________________

____________________________________________________________________________________________________________

Parent/Guardian Signature:

______________________________________________________________________________ Date: ________________________

Year #2: _______________________________________________________________________Date: _________________________

Year #3: _______________________________________________________________________ Date: ________________________

5.

Rev. ‘14

CHILD’S NAME: _____________________________________________________________________ DOB: ____________________

Parent(s) Information:

|Mother: |Father: |

|Phone: |Phone: |

|Age(optional): |Age(optional): |

|Education: |Education: |

Please check.

| |I have attended a preschool session with my child prior to enrollment. |

| |I have visited Busy Bees prior to enrollment. |

| |I have received a Parent Handbook with my child file. |

| |I was able to share pertinent information about my child. |

| |I was given answers to questions or concerns about my child and about the program. |

| |I know where to find: Busy Bees Health Care Policy Handbook, DEEC Regulations, and NAEYC Accreditation Criteria. |

| |I understand I can visit the site any time unannounced. |

Why did you choose Busy Bees Preschool Center? (Check one or more.)

|Advertising |Newspaper |Relative |

|Friend |Pediatrician/clinic |Resource& Referral agency |

|Location |Phone directory |Reputation |

|NAEYC accredited |Professional agency |Word of mouth |

|Other: |

Parent Involvement Options

Check one or more choices of ways to get involved in your child’s first world experience outside the home!

| |Artwork | |Assist at preschool parties/events |

| |Coordinate parent/child group activities | |Conduct a parent workshop |

| |Crafts/sewing | |Share a skill/job |

| |Donate clothing/materials | |Facilitate parent meetings |

| |Serve on Busy Bees Parent Committee | |Provide a site for field trips |

| |Play games/sports with preschoolers | |Music/singing |

| |Read stories, puppets, felt board | |Videotaping |

| |Translation | |Share a second language |

| |Writing/topics for monthly newsletter | |Word processing |

6.

Rev.’14

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