Child Enrollment Packet

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Emergency Contact/Parental Consent Form

Child's Name:(Required)

First Last

Birth Date:(Required)

MM slash DD slash YYYY

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Mother's Name/Legal Guardian:(Required)

First Last

Home Address:(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone:(Required)

Cell Phone:(Required)

Business Name:(Required)

Business Address:(Required)

Street Address Address Line 2 City State ZIP Code

Business Phone:(Required)

Email Address:(Required)

Father's Name/Legal Guardian:(Required)

First Last

Home Address:(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone:(Required)

Cell Phone:(Required)

Business Name:(Required)

Business Phone:(Required)

Business Address:(Required)

Street Address Address Line 2 City State ZIP Code

Email Address:(Required)

Emergency Contact Person's Name(Required)

First Last

Phone Number when child is in care:(Required)

Person(s) to whom child may be released:

Name of Child's Physician/Medical Care Provider:

Phone Number:

Address:

Street Address Address Line 2 City State ZIP Code

Special disabilities (if any):

Allergies (including medication reaction):

Medical/Dietary information necessary in an emergency situation:

Medical, Special conditions

Additional information on special needs of child:

Health Insurance Coverage/Medical Assistance Benefits for Child:

Policy Number:

Parent Signature (Obtaining Emergency Medical Care):(Required)

Parent Signature (Admin. of Minor First Aid Procedures):(Required)

Parent Signature (Walks and Trips):(Required)

Parent Signature (Swimming):(Required)

Parent Signature (Transporation by the Facility):(Required)

Parent Signature (Wading):(Required)

Fee Agreement

Child's Name:(Required)

First Last

Child's Arrival Time:

Child's Departure Time:

Person(s) designated by parent whom child may be released:

I, the parent/guardian received complete written program informaiton at the time of enrollment.(Required)

I authorize

I, the parent/guardian agree to update the emergency contact/parental consent form information whenever changes occur or every 6 months at a mininum.(Required)

I authorize

Signature of Parent/Guardian:(Required)

Date:(Required)

MM slash DD slash YYYY

Child Health Report

Child's Name:(Required)

First Last

Parent/Guardian:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Home Phone:(Required)

Address:

Street Address Address Line 2 City State ZIP Code

Work Phone:(Required)

I authorize the child care staff and my child’s health professional to communicate directly if needed to clarify information on this form about my child.(Required)

I authorize

Parent's Signature:

HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND DIAGNOSIS/TREATMENT IN EMERGENCY (DESCRIBE, IF ANY):

DESCRIBE ALL MEDICATION AND ANY SPECIAL DIET THE CHILD RECEIVES AND THE REASON FOR MEDICATION AND SPECIAL DIET. ALL MEDICATIONS A CHILD RECEIVES SHOULD BE DOCUMENTED IN THE EVENT THE CHILD REQUIRES EMERGENCY MEDICAL CARE.

CHILD’S ALLERGIES (DESCRIBE, IF ANY):

LIST ANY HEALTH PROBLEMS OR SPECIAL NEEDS AND RECOMMENDED TREATMENT/SERVICES. ATTACH ADDITIONAL SHEETS IF NECESSARY TO DESCRIBE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHILD, INCLUDING INDICATION OF SPECIAL TRAINING REQUIRED FOR STAFF, EQUIPMENT AND PROVISION FOR EMERGENCIES.

IN YOUR ASSESSMENT, IS THE CHILD ABLE TO PARTICIPATE IN CHILD CARE AND DOES THE CHILD APPEAR TO BE FREE FROM CONTAGIOUS OR COMMUNICABLE DISEASES?(Required)

Yes

HAS THE CHILD RECEIVED ALL AGE APPROPRIATE SCREENINGS LISTED IN THE ROUTINE PREVENTIVE HEALTH CARE SERVICES CURRENTLY RECOMMENDED BY THE AMERICAN ACADEMY OF PEDIATRICS? (SEE SCHEDULE AT WWW.AAP.ORG)(Required)

Yes

RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD’S IMMUNIZATION RECORD

HEP-B DATES:

ROTAVIRUS DATES:

DTAP/DTP/TD DATES:

HIB DATES:

PNEUMOCOCCAL DATES:

POLIO DATES:

INFLUENZA DATES:

MMR DATES:

VARICELLA DATES:

HEP-A DATES:

MENINGOCOCCAL DATES:

OTHER:

MEDICAL CARE PROVIDER:

Address:

Street Address Address Line 2 City State ZIP Code

Phone:

Civil Rights Compliance Parent Awareness

In accordance with applicable Federal and State civil rights laws and regulatory requirements, you and your children, as clients of this facility, have the right to:

Be provided services at this facility and to be referred for services at other facilities without regard to your race, color, religious creed, disability, ancestory, national origin, age or sex.

Program services shall be made accessible to eligible persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to, equipment redesign, the provision of aides, and the use of alternative service delivery locations. Structural modifications shall be considered only as a last resort among available methods.

Any individual/client/patient/student (and/or their guardian) who believes they have been discriminated against, may file a complaint of discrimination with:

Complaints of discrimination may be filed with any of the following:

Schoolhouse Learning Center, Inc.
910 Town Center
New Britain, PA 18901

PA Human Relations Commission
Philadelphia Regional Office
110 North 8th Street, Suite 501
Philadelphia, PA 19107

Department of Public Welfare
Bureau of Equal Opportunity
Room 223, Health and Welfare Building
P.O. Box 2675
Harrisburg, PA 17105

Commonwealth of Pennsylvania
DPW Bureau of Equal Opportunity
Southeast Regional Office
801 Market Street, Suite 5034
Philadelphia, PA 19107

Office for Civil Rights
U.S. Department of Health and Human Services
Suite 372, Public Ledger Building
150 S. Independence Mall West
Philadelphia, PA 19106-9111

Parent Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

Diaper Cream Policy

This form gives consent to apply diaper cream (that has been supplied by you) to your child, when necessary. The following procedure will be followed, assuming that we have the form completed and signed by the parent or guardian.

Diaper cream will be labeled with your child's name and be provided by the parent/guardian.
You will be notified verbally and by a note when it is necessary to replenish your supply of diaper cream for your child.
The diaper cream will be applied using a facial tissue, toilet tissue or wearing a clean disposable glove to the area that needs it.
A staff member will make a phone call or a note will be written to the parent or guardian if there are any skin problems such as redness, skin cracks, or bleeding.

Please sign the below consent form. If you choose not to sign below, diaper cream will not be applied at any time to your child by the staff at Schoolhouse Learning Center, Inc.

I give my consent for my child to receive an application of diaper cream by his/her teacher at Schoolhouse Learning Center. Diaper cream will be labeled with your child's name and will be provided by me, the parent or guardian.

Child's Name:(Required)

First Last

Parent/Guardian Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

Child Tylenol Policy

Dear Parents:

Occasionally a child will develop a high “fever at the spur of the moment.” After taking the child's temperature, we will call the parent or guardian if it is 100 degrees or above. We will then ask you if we can administer Tylenol and what dosage we should give. You will then be required to pick up your child. The teacher will administer the medication and write it in the medication log. When you arrive, you will be asked to sign the medication log.

In the event we are unable to reach you and the temperature is 100 or above we will administer Tylenol, see bottom of form. If after Tylenol is given and the temperature reached 103 degrees, a Schoolhouse Learning Center employee will take your child to the nearest hospital. It is because we are aware of the effects a high temperature can have on a child that we have decided to follow this procedure.

Schoolhouse Learning Center does not supply Tylenol. Please be sure to give your child's teacher a bottle we may keep at school. We cannot accept medication that is not in the original container. Please label the bottle with your child's name.

Please inform us at drop off any medication you have administered earlier, the time and the amount of dosage given. If you have any questions or concerns please do not hesitate to stop in the office or call.

Child's Name:(Required)

First Last

Tylenol:(Required)

Stage One Concentrated Drops

Stage Two (Ages 2+)

Stage Three (Ages 3+)

Stage Four (Ages 6+ Junior Strength)

Dosage:(Required)

Signature of Parent/Guardian:(Required)

Date:(Required)

MM slash DD slash YYYY

Sunscreen Policy

According to the Department of Human Services regulations Schoolhouse Learning Center’s policy on Sunscreen Application is as follows:

Sunscreen is to be provided by the parent/guardian.
Weather permitting, your child will have sunscreen applied to exposed areas.
You will be notified verbally, and by a note in your child’s cubby, when it is necessary to replenish your supply of sunscreen
The sunscreen will be applied before your child is engaged in any outdoor activities.

Please sign the below consent form, if you choose not to sign below, sunscreen will not be applied to your child at any time by our Staff.

I give consent for my child to receive the application of sunscreen by his/her teacher at Schoolhouse Learning Center, Inc. Sunscreen will be provided by me, the parent or guardian.

Child's Name:(Required)

First Last

Parent Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

Parent Handbook & Important Info

I have read, understand, and agree to abide by the Rules and Regulations of Schoolhouse Learning Center, Inc. as stated in the revised version of the online Parent Handbook at schoolhouselearningcenter.net (located under resources)

I have also read the following "Important Information" on the www.schoolhouselearningcenter.net (located under Resources)

CHIP: Children's Health Insurance Program, Pennsylvania's program to provide health insurance to uninsured children and teens who are not eligible for or enrolled in Medical Assistance.
Child Care Tax Deduction: You may be able to claim the child and dependent care credit if you paid expenses for the care of a qualifying individual to enable you (and your spouse, if filing a joint return) to work or actively look for work.
Stars: Keystone STARS is Pennsylvania's Quality Rating and Improvement System (QRIS). A QRIS is a continuous quality improvement systemic approach to assess, improve, and communicate the level of quality in early and school-age care and education programs. Keystone STARS is a program of Pennsylvania's Office of Child Development and Early Learning (OCDEL).
Child Care Works Subsidized Child Care Program: The subsidized child care program helps low-income families pay their child care fees. The state and federal governments fund this program, which is managed by the Early Learning Resource Center (ELRC) office located in the county.

Parent Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

Photograph/Video Permission

Schoolhouse Learning Center will take photographs or videos of the children participating in our program from time to time. And these may appear in various news releases, websites and other publicly materials (for example: brochures, coupons, documenting daily activites for assessment purposes, classroom purposes, trainings, and websites).

I give Schoolhouse Learning Center permission to take photos or videos for the purposes listed above.(Required)

Yes

We are excited to share with you that Schoolhouse Learning Center has a Facebook page! We are always busy adding new information, photos, and videos so you will be able to visit and see what we have going on at the center. We have personalized our site by including pictures of artwork, creations, and children active at the center.

I give Schoolhouse Learning Center permission to post my child's picture or video on the center's Facebook page.(Required)

Yes

By signing below, you are giving your permission for Schoolhouse Learning Center to take photographs or videos for these purposes that you have checked above.

Child's Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Signature of Parent/Guardian:(Required)

Date(Required)

MM slash DD slash YYYY

Transportation Consent

Child's Name:(Required)

First Last

School Year:(Required)

Birth Date:(Required)

MM slash DD slash YYYY

Grade:(Required)

Student's Elementary School:(Required)

My child will attend School House Learning Center:(Required)

Before Care

After Care

My child will attend the before school program at SHLC on: (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

My child will attend the after school program at SHLC on: (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Consent(Required)

I give my consent for Schoolhouse Learning Center to transport my child to and from school and on any scheduled field trips. I understand that School House Learning Center reserves the right to make emergency decisions (not taking any child to school, picking the child up early or late) due to weather or sudden occurences. All decisions are made with the safety of the children and staff being the first priority. This must be approved by the director.

Parent Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

Getting to Know You at Enrollment Time

Child's Name:(Required)

First Last

Start Date:(Required)

MM slash DD slash YYYY

Birth Date:(Required)

MM slash DD slash YYYY

Family Composition Questions:

Tell us about your household (who lives there, names and relationship to child).

Are there any custody issues that we should discuss? Is there someone whom with your child may not leave Schoolhouse Learing Center with?

Does your child have any siblings? If so, what are their names and ages?

Child Information:

Has your child previously attended an Early Learning Program?

Does your child have any fears?

Any special needs? (medical, developmental, social or mental health)

Do any of these special needs require special care by our teachers?

Are there any special problems or fears we should know about?

Does your child have any allergies?

How are your child’s allergies treated?

Do you have any special medical or dietary information for management in an emergency situation? For example, medicine to keep on hand, people to call, etc.

IEP

Child's Name:(Required)

First Last

Your child's growth and development is measured with developmental assessments. If your child currently has an IEP/IFSP, it would be beneficial to share a copy of this plan with us so we can provide consistency in your child's care.

You do not have to provide this information if you do not wish to do so.

My child has an IEP/IFSP.

Yes

I am providing a copy of my child's IEP or IFSP.

Yes

I give permission for anyone working with my child to communicate with Schoolhouse Learning Center regarding my child's plan and for a representative from Schoolhouse to be present at any team meetings regarding that plan.

Yes

A conference with your child's teacher is required prior to your child's enrollment at any of our centers.

Parent Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

FREE REGISTRATION at initial enrollment.

When submitting your completed enrollment packet to the center director, mention the code 'FREE REGISTRATION' and receive a one time credit for free registration. This offer is for new families only.

Note: Upon Availability.