AFTER SCHOOL PROGRAM CHILD'S FACE SHEET/ENROLLMENT FORM

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AFTER SCHOOL PROGRAM

CHILD'S FACE SHEET/ENROLLMENT FORM

CHILD INFORMATION

Child's Name: _________________________________________ Date of Birth: ___________________ Home Address: _________________________________________ Telephone: ____________________ School attending for 2014/15 school year: _____________________ Primary Language: ______________ Child's Identifying Information (required by the Department of Early Education and Care):

Eye Color: _________ Hair Color: __________ Sex: ______ Height: ______ Weight: ______ Skin Color: _________ Identifying Marks: ________________________________________________________________________________ PARENT/GUARDIAN INFORMATION Parent/Guardian Name: ________________________ Relationship to Child: __________________________ Home Address: _______________________________ Home Telephone: _____________________________ Mobile Phone: ________________________________ Preferred Email: _______________________________ Secondary Email: _____________________________ Work Name/Address: ___________________________ Work Telephone: ______________________________ Hours at Work: From:____________To:____________

Parent/Guardian Name: ________________________ Relationship to Child: __________________________ Home Address: _______________________________ Home Telephone: _____________________________ Mobile Phone: ________________________________ Preferred Email:_______________________________ Secondary Email: _____________________________ Work Name/Address : _________________________ Work Telephone: _____________________________ Hours at Work: From:____________To:____________ CHILD'S PHYSICIAN & MEDICAL INFORMATION

Physician Name: ________________________________ Telephone Number: _________________________________ Address: _____________________________________ Fax Number: ______________________________________ Allergies/Special Diet: Yes____ No_____ (If yes, explain)________________________________________________ Individual Health Plan for child with a chronic health condition? Yes_____ No_____ (if yes, please attach)

Copies of any custody agreements, court orders, and restraining orders pertaining to the child? Yes___No___

(if yes, please attach).______________________________________________________________________________ Special Limitations or Concerns: Yes___ No___ (If yes, explain)_____________________________________________

By signing below, I have read and understand the contents of this page.

Parent/Guardian Signature: ___________________________________ Date ____________________ FOR WCCC USE: Date of Admission: ___________ Age at Admission: __________ Site: ________________

2014/2015 School: ____________School Address: ___________________________School Phone:____________ I certify that documentation of physical examination and immunizations in accordance with public school health requirements, and lead poisoning screening in accordance with public health requirements are on file at my child’s school. Parent/Guardian initials: _______________

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AFTER SCHOOL PROGRAM

HEALTH CARE, EVACUATION, &

PARENT HANDBOOK/POLICIES CONSENT FORM

Child’s Name________________________________________ Date of Birth____________________________________ Parent/Guardian Name_________________________________ Reachable Phone________________________________ Parent/Guardian Name_________________________________ Reachable Phone________________________________ FIRST AID AUTHORIZATION

I authorize WCCC teachers who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate. EMERGENCY MEDICAL CARE

I understand that every effort will be made to contact me in the event of an emergency requiring medical treatment, including but not limited to an epinephrine auto-injection for suspected exposure to a life threatening allergen for my child when delay would be dangerous to the health of my child. 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.

Physician Name _______________________Address__________________________Phone Number_________________ Health Insurance Coverage: _________________________________________ Policy # ___________________________ Child’s Allergies_____________________________________________________________________________________ Chronic Health conditions_____________________________________________________________________________ EMERGENCY EVACUATION

In the case of a catastrophic emergency, I give WCCC permission to transport my child by reasonable means to a location deemed appropriate by WCCC, Town of Wellesley police or fire departments or Wellesley College campus police. I understand I will be notified as soon as possible.

PARENT HANDBOOK/POLICIES AGREEMENT

I am aware that the WCCC Parent Handbook/Policies are located on the WCCC website After School Policies page, and acknowledge that I am responsible for knowing the contents.

The link can be found at: http://www.wccc.wellesley.edu After School Policies Tab By signing below, I have read and understand the contents of this page.

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AFTER SCHOOL PROGRAM

PICK UP CONSENT FORM

Child’s Name________________________________________

PICK UP LIST

(in order to be contacted in the case of an emergency)

We must have written authorization from you to allow another person to pick up your child. We cannot accept phone calls for pick-up authorization. It is our policy to request photo identification from anyone unfamiliar to us. Please inform those on your pick-up list that we must have proper photo identification in order to release your child.

I give permission for the following people to pick up my child from WCCC in an emergency or when I notify the program:

1. Name________________________________________Physical Description__________________________________ Address:________________________________________Relationship to Child:__________________________________ Home Phone #__________________________________ Cell Phone #_________________________________________ Do you give permission for child to be released to this person? Yes_____ No____

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AFTER SCHOOL PROGRAM

TRANSPORTATION, OFF SITE, FIELD TRIP & PLAYGROUND CONSENT FORM

Child’s Name: ___________________________________________

Please check the appropriate line for how your child will arrive/depart from the program. Please note that all children grades 1-8 will arrive to the program via “Unsupervised walk from his/her classroom”

My child will arrive at the program by: My child will depart from the program by:

____Supervised walk from his/her classroom ____Parent pick-up

____Unsupervised walk from his/her classroom ____By an authorized adult from my pick-up list

____Program bus or van ____Emergency Contact

OFF-SITE ACTIVITIES PERMISSION

I give permission for my child to participate in all of the regularly scheduled on-going activities located at the following off-site facilities:

Wellesley Public Libraries Boulder Brook Reservation Babson College The Brook Path Wellesley Fire Stations Wellesley Duck Pond Linden St. Shops & Restaurant WCCC Early Childhood Program Wellesley College Wellesley Fells Area Forest St. Restaurants Lower Falls Area

Wellesley Police Station Kelly Memorial Park Warren School Playground

Longfellow Pond Area Dana Hall School The Wok Restaurant

Tenacre Country Day School Cedar Street Playground All Wellesley Public Schools Wellesley Downtown Area Shops

FIELD TRIP PERMISSION

You have my permission to take my child on trips that the Wellesley Community Children’s Center plans. I understand that I will be notified in writing of all trips requiring transportation in advance. I also understand that all necessary precautions will be taken to ensure his or her safety, and I will not hold the Wellesley Community Children’s Center responsible for any accident, which may occur on such a trip.

PLAYGROUND ACTIVITIES INFORMATION

Almost daily, children enrolled in WCCC’s After School programs play on the school playgrounds. At one point our licensor asked about playground supervision. We want you to know that we are happy to see children playing both with friends enrolled in our programs as well as friends from the neighborhood. WCCC teachers supervise your children, but they are not responsible for the play of those not in our care.

While it might seem obvious, we are informing you of our policy that, while playing on the playground during after school hours at WCCC, we require children in our care to follow both rules established by the schools and WCCC regarding playground use.

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AFTER SCHOOL PROGRAM

PERMISSION CONSENT FORM

Child’s Name: ___________________________________________ PHOTO PERMISSION

Throughout the year various newspapers and magazines ask to photograph the children while they are at After School. Pictures might include walks, parties, or a child playing indoors or outside. Please check below.

_______ I give permission for my child to be photographed while attending the WCCC After School Program. _______ I do not wish my child to be photographed while attending the WCCC After School Program.

--- OBSERVER PERMISSION

WCCC hosts observers throughout the year from other children’s centers, colleges, high schools, and the community, as well as our own consultants. The Massachusetts Department of Early Education and Care requires that parents sign a general consent form to indicate their awareness that observers are permitted at the After School Program sites. Observers are scheduled by the Director so as not to interfere with the children’s program and general after school program routines. Observers may not interact with any child unless special consent from parents is obtained in writing and a detailed description of the interaction is furnished to parents.

--- EMAIL, ADDRESS & PHONE LIST PERMISSION

Each year WCCC distributes a list of family addresses and phone numbers to families currently enrolled at WCCC's After School Program. Please check below:

______ I want to be included in WCCC's list of families. ______ I do not want to be included in WCCC's list of families.

--- WEBSITE PERMISSION

The WCCC website includes some photographs of children at play. The children are not identified by name, age or classroom. Photographs will be shown to parents before they are mounted on the site.

______ I give permission for my child’s photograph to be used on the WCCC website. ______ I do not wish my child’s photograph to be used on the WCCC website. By signing below, I have read and understand the contents of this page.

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AFTER SCHOOL PROGRAM

ORAL HEALTH PARTICIPATION CONSENT FORM

Child’s Name: ________________________________________

In January 2010, EEC issued new regulations for child care programs that include a requirement that educators assist children with brushing their teeth if children are in care for more than four hours or if children have a meal while in care [606 CMR 7.11(11)(d]. This regulation is intended to:

• Help children learn about the importance of good oral health

• Provide information and resources regarding good oral health to child care programs and families

• Help address the high incidence of tooth decay among young children in Massachusetts, which is associated with numerous health risks.

EEC licensed programs must comply with this regulation. However, parents may choose that their child (ren) not participate in tooth brushing while present at the childcare program.

Please check one of the following:

______I do not wish to have my child participate in tooth brushing while in care at Wellesley Community Children’s Center After School Program.

______I would like to have my child participate in tooth brushing while in care at Wellesley Community Children’s Center After School Program.