Patterson Avenue Child Care Program

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					Patterson Avenue Child Care Program

                     General Information
Date Enrolled                                                Date
Enrolled
Child’s Full Name:                      Date of Birth:
Nickname:
Mother’s Name:                                     Social Security
Number:
Mother’s Address:                                  Work Telephone
Number:
                                      Home Telephone Number:


Mother’s Occupation:                           Place of Employment:


Father’s Name:                                     Social Security
Number:
Father’s Address:                                  Work Telephone
Number:
                                      Home Telephone Number:


Father’s Occupation:                           Place of Employment:


Marital status of child’s parents::                 Does child live
with both parents?           If not, which:?
Other     children in the family (names and ages)




        Child’s rank in family:
Adults in family (names child calls adult and relationship):




OPTIONAL – Religious affiliation of child:



Previous group/school experiences (if applicable):




Pets (names, type):


Favorite play materials/toys:




Describe any special experiences problems, concerns, habits,
etc. that will help us serve your child better:




Reason for requesting placement in this setting:



Patterson Avenue Child Care Program

                      Emergency Information
Who has physical custody of child? (Circle all that apply)
                                           Mother      Father Both     Other
NAMES OF INDIVIDUALS AUTHORIZED TO PICK UP THE CHILD AT ANY TIME INCLUDING PARENTS:


    (Child will not be able to leave with any other person without written
                      authorization from parent or guardian)
INDIVIDUALS (OTHER THAN PARENTS) WHO MAY BE CALLED AND MAY PICK UP IN THE CASE OF AN
EMERGENCY:
      Name                Address                    Telephone           Relationship
1. (required)


2. (required)


3. (optional)


PHYSICIAN AND DENTIST TO BE CALLED IN THE CASE OF AN EMERGENCY:
physician                        Address                          Insurance Plan #
             Telephone


Dentist                          Address
      Telephone




If physician cannot be reached, what action should be taken?




Hospital preference (if any):


Approximate daily schedule of child:




What allergies should we be aware of?


Person(s) responsible for tuition account:


Social Security Number Mom                 -    -           Social Security
Number Dad          -     -



Patterson Avenue Child Care Program
                                    Health Information
Has child been under regular supervision of physician?
             Date of last examination:
D E V E L OP M E N TA L HI S T O RY :
Walked at:                               months.           Talked at:                            months.
Toilet training started at:                                   months.
P A S T IL L N E SS – C H E C K T H OS E T HA T AP P L Y A N D P R O V ID E AP P R O XIM A T E DA T E S :
                     Dates                                              Dates
                   Dates
Chicken        Pox                         Diabetes                       Poliomyelitis               
Asthma                                Epilepsy                   Ten    Day Measles (Rubeola)
         
Rheumatic         Fever                    Whooping     Cough             Three     Day Measles
(Rubella)                    
Hay Fever         Mumps                       
List other serious or severe illnesses or accidents:
Does child have frequent colds?                                          How many in the past
year?
D A I L Y R O U T IN E S :
What time does child get up?                         What time does child go to bed?
             Does child sleep well?
Does child take naps during the day:?                                    How often?
When?                  How Long?
D I E T PA T T E RN :
             Time Eaten:                             Items Eaten:                      General
Information:
Breakfast:                                                               Any eating problems?


Lunch:                                                                   Any food dislikes?


Supper:                                                                  Length of typical
meal?
Are bowel movements regular?                                  What is the usual time?
         Needs help wiping?
Words used for bowel movement:                                                          Words used
for urination:
Parents’ evaluation of child’s overall health:
Parents’ evaluation of child’s personality:




How does child get along with parents, siblings and other
children?
Has the child had group play experiences?         Does the child
have any special problems or fears? (explain)


What is the plan for care when child is ill?




Patterson Avenue Child Care Program

        Additional Policies and Guidelines
Philosophy:      Our primary goal is to provide a safe, positive
environment that will allow each child to learn, to grow and to
develop social relationships with other children. We strive to
build positive character and behavior by focusing on the core
values of caring, honesty, respect and responsibility. In
keeping with the Christian principles of PACCP, we begin each
day with a devotional that may include a Bible story, Christian
songs, memory verses and a discussion of Biblical value. We also
sing a blessing before lunch and snacks.

Fees:     The weekly tuition is due on Monday of each week.   A
$20.00 later fee will be applied to unpaid accounts on Tuesday.
If your child does not attend school prior to Tuesday, you must
call and make arrangements to pay when your child first attends
for the week. Otherwise, a late fee will be assessed.

Enrollment Items:     A current and complete copy of your
child’[s physical and immunization record, as well as a Birth
Certificate or Certificate of Live Birth, is due by the first
day of attendance at PACCP. You must update your child’s
medical records as requested by PACCP for continued enrollment.
Pick up Procedure:     Children will be released only to those
persons listed in the “authorized to pick-up” of the
Registration Form. Persons listed must be at least 18 years of
age. A picture Identification Card is required of persons
picking up children until staff are familiar with authorized
person.

In the case of separated or divorced parents where visitation
rights are to be denied, a court decree stating such must be
provided for our files. Otherwise, either parent will be
allowed to pick up at any time.

If any parent of authorized individual arriving to pick up a
child is perceived to be under the influence of drugs or
alcohol, the child will not be released, and the proper
authorities will be notified.

In emergency situations only, changes or additions to pick-up
authorizations may be made by telephone. Otherwise, changes or
additions must be made in writing.

Whenever possible, parents should call PACCP at 358-2767 when
they will be late for pick-up. This will enable us to notify
your child as well as make staffing arrangements. Alternate
pick-up arrangements should be attempted first. A late pick-up
fee of $1.00 per minute will be charged for each minute late
after the time the child is scheduled to be picked up.

Items needed at PACCP:      Each child will need a cot sheet and
blanket for nap time. These will be sent home each Friday for
laundering. Toys are not permitted other than for Show and Tell.
A season-appropriate change of clothing is required to remain at
PACCP and must be replaced upon use. Diapers, wipes and
ointments (if applicable) must be replenished as needed.




Patterson Avenue Child Care Program

                Admissions Agreement:
I have read all the information provided describing the
program and am confident that the Patterson Avenue
Child Care Program is able to adequately address my
child’s needs based on my child’s health, physical and
emotional development. I have completed all the forms
and will provide PACCP with any and all information
requested. I agree to the program schedule and fees as
described below.

My child is enrolling in the following: (please check
those that apply)
Full Day Plan            Half Day Plan

Full Week               Four Day              Three Day
      Two Day

Morning            Afternoon
Applicable Fees: $50.00 Registration Fee (one time fee
with uninterrupted enrollment)

              $          Weekly Tuition Fee

    Date                  Parent/Agency
Representative/Guardian Signature

          Consent for Medical Treatment
As the parent, agency representative or legal guardian, I
hereby give consent to the Patterson Avenue Child Care Program
to provide all emergency dental or medical care prescribed by a
duly licensed physician (M.D.) or dentist (D.D.S.) for
                              .   This care may be given under
whatever conditions are necessary to preserve the life, limb or
well being of my dependent.


    Date                  Parent/Agency
Representative/Guardian Signature

         Birth Certificate verification
Date   Admissions Director

				
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