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King’s Chapel
Early Care & Education Center
Child’s Name: ________________________________________ Start Date: __________________
Welcome to King’s Chapel, where we are committed to the education and development of children of all ages! We believe that children should always feel comfortable and secure in their surroundings, especially if these environments are new to them. To help smoothly and comfortably transition children into our program, we have developed detailed enrollment requirements and a comprehensive orientation process that will familiarize both parents and children with program policies, educational components, and our team of teaching professionals. Pursuant to this goal, we require that all families complete/return the following before children may be admitted:
Completed all forms in this enrollment packet
Proof of Residency (utility bill, etc.)
Proof of Family Income (paystubs, unemployment checks, social security checks, budget sheets, etc). Documentation of full months’ pay must be submitted
Child’s Birth Certificate
Child’s Social Security Card
Child’s Insurance Card
Photo ID of Parent/Guardian
Current Physical (ED 119)
Immunization Record
Proof of flu vaccination (must be within one year)
An “Authorization for the Administration of Medication by Child Day Care Personnel” form, if the child requires medications while in care.
Completed a tour of the facility with a staff member
Completed an hour-long orientation with a knowledgeable staff member
Signed an “Orientation Checklist”
Child completed two-hour visit in his/her classroom
In Signing this I verify that the information I have submitted to King’s Chapel Early Care & Education Training Center is accurate and complete. I have read and understand the policies and procedures outlined in the Parent Handbook, and agree to the terms they require.
_________________________________________________ __________________________
Parent/Guardian Signature Date
_________________________________________________ __________________________
Witness’s Signature Date
Contact Sheet
Child’s Name: __________________________________________________________________________
Child’s Date of Birth: ____________________________________________________________________
Child’s Address: ________________________________________________________________________
Name of Parent/Guardian #1: ____________________________________________________________
Home Phone #: _____________________________ Cell Phone #: _______________________
Parent #1 Address: _______________________________________________________________________
Employer: _________________________________ Work Phone #: ____________________________
Parent #1’s Work Address: ________________________________________________________________
Name of Parent/Guardian #2: _____________________________________________________________
Home Phone #: _____________________________ Cell Phone #: _______________________
Parent #2 Address: _______________________________________________________________________
Employer: _________________________________ Work Phone #: ____________________________
Parent #2’s Work Address: ________________________________________________________________
Names of People in Household:
______________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________ ______________________________________
Child’s/Family’s Religion: __________________________________________________________
Are there any religious or cultural practices that you would like your child to observe while in care?
________________________________________________________________________________
Please specify the hours of care your child requires:
| |Monday |Tuesday |Wednesday |Thursday |Friday |
|From: | | | | | |
|To: | | | | | |
Please indicate the date that this information was provided: ________________________________
Emergency Contact Information
In the event that you are not available to pick up your child at the end of the day, or to tend to a medical emergency or injury, we require that you provide authorization to at least two other individuals to pick up your child and/or receive access to the child’s files and records maintained by the program. In the event of an emergency, if we are unable to contact you, these individuals shall be authorized to make vital medical decisions relating to the child’s medical care.
The emergency contact information should be updated at least every 6 months, or whenever there is a change to contact information. Please let us know if one of the contact people moves or gets a new phone number. You will be asked to fill out a new emergency contact form every December and June.
Emergency Contact #1: __________________________________________________________________
Relationship to Child: ____________________________________ Phone #: _____________________
Address: ________________________________________________________________________________
Emergency Contact #2: ___________________________________________________________________
Relationship to Child: ____________________________________ Phone #: _____________________
Address: ________________________________________________________________________________
Emergency Contact #3: ___________________________________________________________________
Relationship to Child: ____________________________________ Phone #: _____________________
Address: ________________________________________________________________________________
Emergency Contact #4 (optional): ___________________________________________________________________
Relationship to Child: ____________________________________ Phone #: _____________________
Address: ________________________________________________________________________________
Parent/Guardian Signature: __________________________ Date: ______________________
Family Culture and Information Sheet
To help us in our efforts to create an atmosphere that suits your child’s specific needs while celebrating and valuing your child’s unique background, we ask that you take a few moments to tell us a little bit more about your family and your child.
Where are you from originally? ______________________________________________________________
What languages do you speak at home? ________________________________________________________
What language would you like for teachers to speak to your child here? ______________________________
Are there any songs or books that your child particularly likes? If so, we would be happy to integrate these into our classroom to help make your child more comfortable. ________________________________________________________________________________________________________________________________________________________________________________
Does your child have any siblings at home? ____________________________________________________
About how much time would you say that you do literacy activities with your child each day (e.g. reading, singing, talking one-on-one, etc.) ________________________________________________________________________________________________________________________________________________________________________________
What do you feel are your child’s strengths? ________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
In what areas do you feel your child could use support? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What are the goals that you have for your child within the next year? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What can we do to support your family’s culture?
________________________________________________________________________________________
About how much sleep does your child get each night?
________________________________________________________________________________________
Medical History Form
Does your child have any special health problems or health-related requirements of which the center should be aware? __________________________________________________________________________________________________________________________________________________________
Does your child have special conditions or developmental challenges? If so, how can the program support your child to address/overcome these challenges? __________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
Has your child been in Birth to Three? ______________________________________________
Does your child have any allergies to food, medicine or insect bites? __________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________
Does your child have any environmental sensitivities of which we should be aware?
__________________________________________________________________________________________________________________________________________________________
Does your child have any birthmarks, scars, rashes?
__________________________________________________________________________________________________________________________________________________________
What is the name of your child’s physician? __________________________________________
What is the phone number of your child’s physician? __________________________________
Should a medical emergency arise, to which hospital should your child be sent?
_____________________________________________________________________________
Please note that King’s Chapel may only administer medications, prescription and non-prescription, with the written order of a licensed physician. Please see our Administration of Medications policy for more information on these requirements.
Parent Involvement
Here at King’s Chapel, we believe that you are a very important part of your child’s education! Studies have shown that children whose parents are active in their school are more successful at all levels of education. Therefore, we encourage you to volunteer here at our center as often as possible, whether by attending our parent advisory board meetings, reading stories to your child’s class, or chaperoning trips. Anything you give of yourself will be beneficial to your child, the center, and you. How can we count on your support?
Would you like to read stories to the class from time to time? Yes No
Would you like to serve on our Parent Advisory Board? Yes No
Would you like to share a hobby, skill, or trade with your child’s class? If so, what type of hobby?
_______________________________________________________________________________
________________________________________________________________________________
We are very proud of our programs’ diversity and encourage you to share yours. Are there any arts, dances, songs, or activities that are unique to your culture that you would like to share with your child’s class?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Would you like to help chaperone field trips? Yes No
Would you like to volunteer at any of our extra-curricular events? Yes No
Authorization for Video/Photo Release
The program often takes pictures and videos of children engaged in play while in care. While the program typically only uses these photos for board displays and documentation of program activities, some photos may be used for promotional materials or may be placed on newsletters. We request that families authorize the program to take pictures and use them in the following contexts:
- For in-house tasks such as labeling materials, display boards, etc.
- On the central monitor that rotates different pictures of children engaged in their settings.
- On the program’s website or facebook account.
- For teacher observations, as it relates to academic courses they take.
In signing this, the parent/guardian authorizes the program to take pictures of their child, and to use them for displays, promotional materials, and other forms of documentation.
___________________________________________________ ____________________
Parent’s Signature Date
In addition to the above, I authorize King’s Chapel Early Care & Education Center to post pictures of my child on its website and social media websites.
____________________________________________________ ____________________
Parent’s Signature Date
Authorization for Sunscreen Lotion
During the summer months, it may be necessary to protect your child’s skin against harsh sun exposure. If your child wears clothes that leave his/her skin exposed to the sun, the program may choose to apply sunscreen lotion to protect the child’s skin. This lotion has UVA and UVB protection, and is always SPF 15 or higher. In order to take this preventive measure, you, as the child’s guardian, must authorize the program to use this lotion by signing below:
_______________________________________________________ ____________________
Parent’s Signature Date
Authorization for Insect Repellent
During the summer months, insects may frequent our outdoor learning centers. To prevent the spread of disease by these insects, the program may choose, at the recommendation of the Department of Public Health, to apply a chemical insect repellent to your child’s skin. Only DEET-containing repellants shall be used, and may only be applied to children once a day. Children under the age of four months will not be given repellent. In signing below, the parent authorizes our program to apply these repellents to his/her child’s skin.
______________________________________________________ ____________________
Parent’s Signature Date
Authorization to Perform Medical Care
• I hereby grant permission for my child to use play equipment and participate in all of the activities sponsored by King’s Chapel.
• I hereby grant permission for my child to leave the center premises under the supervision of a staff member for neighborhood walks or field trips.
• I hereby grant King’s Chapel staff permission to take whatever steps may be necessary to obtain emergency medical care for my child. These steps may include, but not be limited to, the following:
1. Perform CPR or First Aid as needed
2. Call paramedics or another physician, if so directed
3. Have the child taken to an emergency clinic or emergency room via an ambulance accompanied by a staff member if warranted.
4. Order emergency treatment recommended by the attending physician to sustain my child until the parent/guardian can be located.
• King’s Chapel shall not be held liable for any accidental injury that may occur while the child is in care.
• King’s Chapel will not accept responsibility for a child who has not been signed in when arriving for the day.
________________________________________ _____________________
Parent/ Guardian Signature Date
Infant Feeding Schedule (Infants Only)
Formula child currently consumes: ____________________________________________________
Number of ounces of formula child usually drinks per feeding: ______________________________
How often does the child need a bottle (typically)? : ______________________________________
What baby food is the child eating at this time?: __________________________________________
How much food does he/she eat per serving? ____________________________________________
How often does the child usually eat this food? __________________________________________
Using X’s, please indicate below at what time(s) your child should eat/drink each food/formula item:
|7:00-8:00 |8:00-9:00 |9:00-10:00 |10:00-11:00 |11:00-12:00 |12:00-1:00 |1:00-2:00 |2:00-3:00 |3:00-4:00 |4:00-5:00 | |Infant formula | | | | | | | | | | | |Rice Cereal | | | | | | | | | | | |Fruits/Vegetables | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Demographic Intake Sheet
As our organization is non-profit, much of the funding needed to support the quality of care offered to your children must come to us through donors within the community. However, to give these organizations a better idea as to who we serve in the community, it is important for us to compile records indicating the following demographic information:
1. Is your child:
Male Female
2. Your child is:
1-6 Months 6-12 months 1 year old 2 years old
3 years old 4 years old 5 years old 6 years old
7 years old 8 years old 9 years old 10 years old
11 years old 12 years old 13 years old 14 years old
15 years old 16 years old 17years old
3. The child lives with (please select all that apply):
Single mom Single dad
Grandmother Grandfather
Aunt Uncle
Both mom and dad Mom and stepfather
Father and stepmother Foster Parent
Other (please specify) _________________
4. Which racial category does your child fall under? (if bi-racial, please select ONLY ONE):
African American Latino/Hispanic
White/Caucasian Asian
Pacific Islander Other (please specify)
5. At home, what language is primarily spoken?
English Spanish French
6. How many people are in your household?
2 3 4 5 6 7 8 9 10
7. How many children live under your household?
1 2 3 4 5 6 7 8
8. Has the child for whom you are doing this survey ever been in foster care?
Yes No
9. Does the child for whom you are doing this survey have any special needs?
Yes No
10. Has the child for whom you are doing this survey ever been involved with the Department of Children and Families?
Yes No
11. Which of the following most accurately describes your family’s annual income?
$0-$2,499 $2,500-$4,999 $5,000-$7,999
$8,000-$9,999 $10,000-$11,999 $12,000-$14,999
$15,000-$17,999 $18,000-$19,999 $20,000-$24,999
$25,000-$27,999 $28,000-$29,999 $30,000-32,999
$33,000-$34,999 $35,000-$37,999 $38,000-$40,000
$40,000-$44,999 $45,000-$49,999 $50,000-$59,999
$60,000-$69,999 $70,000-$79,999 $80,000-$89,000
$90,000-$99,000 $100,000-$199,999 $200,000+
BEHAVIOR MODIFICATION TECHNIQUES DISCUSSED WITH PARENTS (19a-79-3a-3)
Rationale: In order to ensure that parents understand the discipline policy with behavior modification techniques used at King’s Chapel Early Care & Education Center, the following information is provided to parents as part of Department of Public Health Child Day Care Center licensing regulations.
Policy: Discipline techniques include positive redirection and guidance, setting clear limits for the children, and continuous supervision of staff during disciplinary action. In the event that a child cannot learn to control him or herself during regular program operation, staff will work with parents to find a solution to modify the behaviors . When behaviors cannot be modified and they continue to affect the regular program operation, staff will work with parents to find alternate care to better meet the needs of the child.
Staff will not use abusive, neglectful, corporal, humiliating or frightening punishment on a child at any time. Restraint of a child will only be used to protect the health and safety of a child.
Staff is not allowed to yell at children, force children to sit in time-out, or discipline in any way that shows disrespect toward a child. In instances where staff behavior is questionable, immediate disciplinary action is taken by the supervisor in charge and a plan initiated for immediate corrective action.
I affirm that this policy has been discussed with me and that I understand the policy and the behavior modification techniques that are used at King’s Chapel Early Care & Educational Center.
___________________________ ___________________________
Parent Signature & Date Supervisor Signature & Date
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