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Countryside Children�s Center by HC120621234346

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									                       Countryside Children’s Center
                           191 Dedham Street Newton, MA 02161
                     C-Side: 617-964-6958 Upper Falls: 617-965-6434
                           www.countrysidechildrenscenterinc.com


            COUNTRYSIDE CHILDREN’S CENTER 2012-2013
                      REGISTRATION FORM

___ Enclosed is my NON-REFUNDABLE one month’s advance tuition
deposit in the amount of ______________.
___ Enclosed is my NON-REFUNDABLE deposit based on the state
childcare assistance I receive.
___ Enclosed is the $75.00 Registration Fee.
I wish to register at this site: ___ Countryside ___ Upper Falls
Child’s Name _________________________ Age ____ Grade (‘12-‘13) ______
Address __________________________________ Zip Code ____________
Teacher’s Name and Room # (To be filled in by CCC)______________________

Parent’s Name _____________________________ Home phone ___________
Work phone ______________________ Cell phone _____________________
E-mail address _________________________________________________

Parent’s Name ____________________________ Home phone ___________
Work phone ______________________ Cell phone _____________________
E-mail address _________________________________________________

Days and Hours of Enrollment ______________________________________
                             ______________________________________
Please Note: Your child is enrolled at CCC for the entire 2012-2013 school year according to
the above registration form, in accordance with CCC’s registration process as stipulated by the
Executive Director. DO NOT CHANGE, DELETE, OR ADD DAYS/HOURS.

PARENT SIGNATURE____________________________________________
Today’s Date __________________________________________________
                       Countryside Children’s Center
                           191 Dedham Street Newton, MA 02161
                     C-Side: 617-964-6958 Upper Falls: 617-965-6434
                           www.countrysidechildrenscenterinc.com


            AUTHORIZATION TO DISPLAY PHOTOS ON WEBSITE

The staff at CCC enjoys taking photos of our children, family members, staff, and afterschool
activities that occur while children attend CCC. Occasionally we display these photos on our
website. By signing below, you are allowing your child’s photo to be displayed. The photo may
be an individual or a group photo.
By signing below, I authorize Countryside Children’s Center to display my child’s photo on the
www.countrysidechildrenscenterinc.com website.
Child’s Name ____________________________________

Parent Signature _________________________________ Date _________________
________ No, I do NOT authorize my child’s photo to be displayed on the website.




                     AUTHORIZATION TO RELEASE RECORDS

To best serve our children’s needs and interests, it may be helpful for us to share
personal and/or academic information with other school staff. By signing this
form, families authorize CCC staff to professionally discuss issues concerning
their child. All information will be handled with discretion and shared with
specific staff members who interact with your child.

Is your child currently on an Individual Education Plan (IEP)? ______________

Please give a brief description of the plan and attach it to this form:



___ I authorize the exchange of my child’s personal records between CCC and
Countryside School professionals.
Name of Child: __________________________ Date: _________________
Parent Signature: _______________________________________________
               Countryside Children’s Center
                   191 Dedham Street Newton, MA 02461
             C-Side: 617-964-6958 Upper Falls: 617-965-6434
                   www.countrysidechildrenscenterinc.com
         THE COMMONWEALTH OF MASSACHUSETTS
      DEEC FIRST AID AND MEDICAL CARE CONSENT FORM
Child’s Name: __________________________ Date of Birth: ____________
I authorize staff in the CCC child care program who are trained in the basics of
first aid/CPR to give my child first aid/CPR when appropriate.
I understand that every effort will be made to contact me in the event of an
emergency requiring medical attention for my child. However, if I cannot be
reached, I hereby authorize the program to transport my child to the nearest
medical care facility and/or to _________________________, and to secure
necessary medical treatment for my child.
Child’s Physician Name: __________________________________________
Address: _______________________________ Phone: ________________
Child’s Allergies: __________________Health Conditions _______________
EMERGENCY CONTACTS (In order to be contacted)
Name ________________________________________________________
Address ___________________________ Relationship to Child ___________
Home Phone __________________________ Cell Phone _________________
Do you give permission for child to be released to this person? ___ Yes ____ No
Name ________________________________________________________
Address __________________________ Relationship to child ____________
Home Phone _________________________ Cell Phone __________________
Do you give permission for child to be released to this person? ____ Yes ____No
Name ________________________________________________________
Address __________________________ Relationship to Child ____________
Home Phone ________________________ Cell Phone ___________________
Do you give permission for child to be released to this person? ____ Yes ____No

Health Insurance Coverage ______________________ Policy # ___________

Parent/Guardian Name _________________Work# ________ Cell# _______

Parent/Guardian Name _________________Work# ________ Cell# _______

Parent/Guardian Signature ___________________________ Date ________
                                 Countryside Children’s Center
                                     191 Dedham Street Newton, MA 02461
                               C-Side: 617-964-6958 Upper Falls: 617-965-6434
                                     www.countrysidechildrenscenterinc.com


                                    PARENT INVOLVEMENT FORM
All parents must sign up to assist the Center in some form. Please designate which position you would prefer for next year.
If more than one job appeals to you, please rate them in order of preference. If this form is not returned, you will be
assigned by the Director as needed and you will be considered responsible for that job.


___FUNDRAISER COMMITTEE PARENT: Agrees to attend meetings in order to select and implement at least one
fun-filled fundraiser during the year.

___SKI PROGRAM PARENT: Aids staff in chaperoning a minimum of three specific ski field trips during Jan./Feb.
ski season. Ski Program is always on Tuesday.

___SNACK PARENT: Provides same snack for at least 75 children at our school site, and for at least 50 children at our
Upper Falls Site, one time during the school year. Director will assign the date for snack at a later date. NO FOODS
CONTAINING NUTS, and NO CANDY, please.

___STAFF LUNCHEON PARENT: Provides a lunch for teachers (approximately 15) on one TUESDAY per year,
usually to be delivered at our Upper Falls site about 11:30 AM. Date will be assigned by Director at a later date.




Child’s Name__________________________Parent Signature_____________________
                                 Countryside Children’s Center
                                     191 Dedham Street Newton, MA 02461
                               C-Side: 617-964-6958 Upper Falls: 617-965-6434
                                     www.countrysidechildrenscenterinc.com
                                  PICK UP AUTHORIZATION FORM

The following people are authorized to pick up my child from CCC:

Name________________________________________________________
Home Phone ________________________ Cell Phone ________________

Name ________________________________________________________
Home Phone _______________________ Cell Phone _________________

Name ________________________________________________________
Home Phone _______________________ Cell Phone _________________

Name ________________________________________________________
Home Phone _______________________ Cell Phone _________________




                                   LATE PARENT AUTHORIZATION
As the parent/guardian of _______________________________, I hereby authorize a Countryside Children’s Center staff
member to take care of my child should I be unable to pick him/her up by 6:00 PM, according to the afterschool clock. I
also understand that there is a LATE FEE of $1.00 PER MINUTE PER CHILD.
Parents who pick up at 3:30 PM, but are late in picking up, must also pay a LATE FEE of $1.00 PER MINUTE PER
CHILD, according to the afterschool clock. If a child is not picked up in a timely fashion, CCC staff has authority to call
the Newton Police for assistance.


Parent/Guardian Signature__________________________________________________


Date____________________________________________________________________
                                  Countryside Children’s Center
                                      191 Dedham Street Newton, MA 02461
                                C-Side: 617-964-6958 Upper Falls: 617-965-6434
                                        www.countrysidechildrenscenterinc.com
                                   STUDENT HEALTH FORM 2012-2013

I certify that my child’s health records are on file at the child’s school. I also certify that my child has received a lead
screening and that the results of said screening are on file at the child’s school.


Child’s Name__________________________________________________

Parent/Guardian Name___________________________________________

Parent/Guardian Signature________________________________________

Date_________________________________________________________




                                   EMERGENCY RELEASE FORM

I understand the staff at the Countryside Children’s Center is trained in the basics of first aid and I authorize them to give
my child first aid when appropriate.

In the event that my child, ___________________________________, is seriously injured or becomes seriously ill while
participating in the Countryside Children’s Center, and I or the others listed as emergency contacts cannot be reached, I do
hereby authorize the staff of Countryside Children’s Center to obtain such medical assistance as they deem necessary or
proper, including, but not limited to, appropriate medical assistance, usually at Newton-Wellesley Hospital, or at the
nearest facility, and I do hereby grant permission for said medical staff to administer treatment to insure the health and
well-being of my child.


Parent/Guardian Name_____________________________________________________

Parent/Guardian Signature_______________________________ Date ______________
                      Countryside Children’s Center
                          191 Dedham Street Newton, MA 02161
                    C-Side: 617-964-6958 Upper Falls: 617-965-6434
                          www.countrysidechildrenscenterinc.com


               STUDENT INFORMATION FACE PAGE 2012-2013
Child’s Name______________________________________ Age ___________________
Birth date_________________ Grade _________ Date admitted to CCC ______________
Home address ________________________________________ Zip code ____________
Parent/Guardian Name ______________________________ Occupation ______________
Home address ___________________________________Phone ____________________
E-mail address ____________________________ Cell Phone _______________________
Business Name _____________________________ Business Phone __________________

Parent/Guardian Name ______________________________ Occupation ______________
Home address ____________________________________ Phone ___________________
E-mail address ____________________________ Cell Phone _______________________
Business Name ____________________________ Business Phone ___________________

Child’s Physician __________________________ Office Phone _____________________
Physician’s address _____________________________ Office Phone ________________
Health Insurance Co. ___________________________ Policy Number ________________
Identifying Information (Required by EEC)
   Eye Color _________ Hair Color ________ Height _______ Weight ______ _Sex _____
   Identifying Marks_______________________________________________________
Names and Ages of Siblings _________________________________________________
Primary Language Spoken at Home ____________________________________________
Food Restrictions/allergies _________________________________________________
Does your child have an IHCP form (Individual Health Care Plan)? ________________ If so,
please attach it to this form.
Medical Issues & Other Special issues to be monitored:
_______________________________________________________________________
  If there is a divorce in the family, who is the custodial parent? ______________________
 May your child leave with the non-custodial parent? _________ A copy of the court order
 stating legal custody of the child is the custodial parent, and that he/she states the child
 may not be allowed to leave CCC with the non-custodial parent must be attached.

My child will arrive at CCC by: ____Unsupervised walk       ____Supervised walk (Kdg only)
____ Bus            CCC staff supervise Kindergarten children arriving by school bus at 12:30.
Parent/Guardian Signature _____________________________ Date ________________

								
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