Back-Up Care Advantage Program Registration Materials

Back-Up Care Advantage Program

Registration Materials

Dear Parent,

Welcome to the Back-Up Care Advantage Program!

An important part of preparing for a day of back-up care is ensuring that your care provider

will have the information needed to prepare for a successful day with your child. Our centers

are required to collect specific information and forms to meet state and local licensing

requirements. The attached materials are designed to guide you through the process so all

paperwork is ready when you need to use one of our back-up child care centers. These

materials should be completed and submitted to your care provider on or before your first day

of care. All shaded information is required for full registration. Some centers require that you

sign center-specific consent forms. These will be provided on your first day of care.

Be sure to keep a copy of these materials on hand should you decide to use additional centers.

Because many state and local licensing authorities require that some information be updated

at regular intervals, it is important to check with your provider before each visit to ensure that

all materials are up-to-date.

We’re happy to work with you through the registration process. Please contact your preferred

center-based care provider directly.

We look forward to serving your family soon!

The Back-Up Care Advantage Team

Back-Up Care Advantage Program

Registration Checklist

Child Name:

Child Information Form

(one for each child to be registered)

Parent/Guardian Information Form

(one for each parent/guardian in the family)

Authorization for Release and Emergency Medical Treatment

(one for each child to be registered)

Authorized Non-Parent/Guardian Information Form

(one for each child to be registered)

Medical and Insurance Information Form

(one for each child to be registered)

Photograph of Child*

(see below for photograph requirements)

Photograph of Parent(s)/Guardian(s)*

(see below for photograph requirements)

Photograph(s) of Non-Parent/Guardian Authorized for Release*

(see below for photograph requirements)

Massachusetts - Physicians Statement

(one for each child to be registered - form must be completed by the child's physician)

Massachusetts - Child Enrollment

(one for each child to be registered)

Massachusetts - Developmental History

(one for each child to be registered)

Massachusetts - Emergency Card

(one for each child to be registered)

Massachusetts - Certificate of Immunization

(one for each child to be registered)

Massachusetts - First Aid & Emergency Medical Care

(one for each child to be registered)

Massachusetts - Off Site Activity

Back-Up Care Advantage Program

Child Registration Information

Child Name: Child Date of Birth:

( / / )

(last, first, middle initial) (mm/dd/yyyy)

Child Nickname: Child Gender:

Male Female (please circle)

Child Lives With:

Does your child have any allergies or food restrictions? yes no (please circle)

If yes, please describe:

Does your child have any diagnosed special needs or medical conditions? yes no (please circle) If yes, please describe:

Are your child's activities restricted by any special needs, medical or other conditions? yes no (please circle) If yes, please describe:

Are there any custody arrangements for your child? yes no (please circle)

If yes, please describe:

(A court order with supporting documentation describing custody arrangements and restrictions must be provided.) Regular Care Arrangements:

Child's Primary Language: Sleeping Schedule:

(for children under 36 months only) Toilet Schedule:

(for children under 36 months only) Other Helpful Information:

shaded information is required for full registration and use of a back-up child care program

Parent/Guardian Signature: Date:

Parent/Guardian Signature: Date:

Ch

Pare

Parent/Guardian Name: Relation to Child:

(l

Ho

Home Contact Information Work Contact Information (Required if applicable)

Home Address Work Email Address Em

Please provide information on the child's parent/guardian(s). If the child has more than 2 legal parent(s)/guardian(s) please complete additional

Parent/Guardian Information Form to ensure that all legal parent/guardians are lis

Work Phone & Ext

Work Address Parent/Guardian Information Par (l Ho Ho Par Par Em W Ho Hom Ho ild Name:

Parent/Guardian Information Form

ted on the child's file.

nt/Guardian Information

ast, first, middle initial)

( )

-ployer (Company Name): Cell Phone

( )

-me Email Address Home Phone

( )

-Work City, State, Zip me City, State, Zip

ent/Guardian Name: Relation to Child:

ast, first, middle initial)

( )

( ) -ployer (Company Name):

ork Email Address Work Phone & Ext

Cell Phone

me Email Address Home Phone

( )

-me Contact Information Work Contact Information (Required if applicable)

e Address Work Address

me City, State, Zip Work City, State, Zip

shaded information is required for full registration and use of a back-up child care program

ent/Guardian Signature: Date:

Child Name:

se of C

e: Dat

I authorize center staff to contact and/or release my child to the following representative(s) is purpos

Each child must have at least 1 person other than the child's parent(s) or guardian(s) authorized for

Parent/Guardian Authorization for Emergency Medical Treatment:

Authorized Non-Parent/Guardian Name:

e: Dat

Parent/Guardian Signature: Date:

Center Staff Signature: Date:

irst

or illnes tify me of any

attempt to contact me as the nature of the emergency permits. If I cannot be reached, I authorize

he follow ated by m

local hospital or other medical facility and obtain any necessary medical treatment at my expense.

r aut

Guardian Info

Authorized Non-Parent/Guardian Information Form

Back-Up Care Advantage Program

Parent/Guardian Authorization for

Release of Child and Emergency Medical

Treatment

release and 1 person authorized to make medical decisions in the event of an emergency.

Parent/Guardian Authorization for Relea hild: designated by me for th e:

Authorized Non-Parent/Guardian Name: Authorized Non-Parent/Guardian Name: Authorized Non-Parent/Guardian Name: Authorized Non-Parent/Guardian Name:

Parent/Guardian Signature: Date:

Parent/Guardian Signatur e:

Please provide contact information for authorized non-parent/guardians on the

I understand that center staff is trained in basic f aid and CPR. I authorize center staff to administer first aid to my child for minor injuries ses as appropriate and to no

actions taken. For all other conditions requiring emergency medical treatment, center staff will center staff to contact t ing representative(s) design e to act on my behalf for this purpose. If my representative cannot be reached, I authorize center staff to transport my child to a

Authorized Non-Parent/Guardian Name:

Authorized Non-Parent/Guardian Name: Authorized Non-Parent/Guardian Name:

Parent/Guardian Signatur e:

Please provide contact information fo Authorized Non-Parent/

horized non-parent/guardians on the rmation Form

)

l decisions? for release o

ent/Guar

Home Phone: le)

yes no (please circle) se circle)

yes no (please circle)

Relationship to child:

le) le)

Authorized Non-Parent/Guardian Information Form

An authorized non-parent/guardian is someone other than the parent(s) or guardian(s) who is authorized to pick the child up and or make medical decisions for the child in the event of an emergency when the parent(s) or guardian(s) cannot be reached.

Child Name:

Each child must have at least 1 person other than the child's parent(s) or guardian(s) authorized for release and 1 person authorized to make medical decisions in the event of an emergency.

Authorized Non-Parent/Guardian 1

Authorized Non-Parent/Guardian Name: Relationship to child:

(last, first, middle initial)

( )

-Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone:

( ) - ( )

-Authorized for emergency medical decisions?:

yes no (please circle)

Authorized for release of child?:

yes no (please circle

Authorized Non-Parent/Guardian 2

Authorized Non-Parent/Guardian Name: Relationship to child:

(last, first, middle initial)

Work Phone: (if applicable) Cell Phone: (if applicab Home Phone:

( ) - _{( ) - ( )}

-Authorized for emergency medica : Authorized f child?:

yes no (please circle) yes no (please circle)

Authorized Non-Parent/Guardian 3

Authorized Non-Parent/Guardian Name:

(last, first, middle initial)

Work Phone: (if applicable) Cell Phone: (if applicab Home Phone:

( ) - _{( ) - ( )}

-Authorized for emergency medical decisions?: Authorized for release of child?:

yes no (please circle) yes no (plea

Authorized Non-Par

dian 4

Authorized Non-Parent/Guardian Name: Relationship to child:

(last, first, middle initial)

Work Phone: (if applicable) Cell Phone: (if applicab

( ) - _{( ) - ( )}

-Authorized for emergency medical decisions?: Authorized for release of child?:

Child Name:

Phone:

Authorized Non-Parent/Guardian 2

Authorized Non-Parent/Guardian Information Form

An authorized non-parent/guardian is someone other than the parent(s) or guardian(s) who is authorized to pick the child up and or make medical decisions for the child in the event of an emergency when the parent(s) or guardian(s) cannot be reached.

Authorized Non Parent/Guardian 2

(last, first, middle initial)

Home Phone:

Authorized for emergency medical decisions?: Authorized for release of child?:

(last, first, middle initial)

( ) - ( ) - ( )

shaded information is required for full registration and use of a back-up child care program.

Address

yes no (please circle) yes no (please circle)

Work Phone: (if applicable) Cell Phone: (if applicable)

City, State, Zip

no

Back-Up Care Advantage Program

Each child must have at least 1 person other than the child's parent(s) or guardian(s) authorized for release and 1 person authorized to make medical decisions in the event of an emergency.

Authorized Non-Parent/Guardian 1

Authorized Non-Parent/Guardian Name: Relationship to child:

(last, first, middle initial)

Home Work Phone: (if applicable) Cell Phone: (if applicable)

( ) - _{( ) - ( )}

-Address City, State, Zip

Authorized for emergency medical decisions?: Authorized for release of child?:

yes no (please circle) yes no (please circle)

Authorized Non-Parent/Guardian Name: Relationship to child:

( ) - ( ) - ( )

-City, State, Zip Address

yes no (please circle) yes (please circle)

Authorized Non-Parent/Guardian 3

Authorized Non-Parent/Guardian Name: Relationship to child:

Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone:

Child Name:

Doctor/Clinic Name:

( )

( )

-Medical Insurance Information

Medical Insurance Carrier: Membership ID #:

Affiliate/Preferred Hospital: Hospital Phone ( )

-Dentist Name:

shaded information is required for full registration and use of a back-up child care program. Date: Date: Date:

Medical, Dental and Insurance Information

Doctor Information

Address Line 1 Doctor/Clinic Phone

Fax Address Line 2

City, State, Zip

Employer Providing Insurance: Member Services Phone ( )

Hospital Information -Dentist Information ( ) -Dentist/Clinic Phone Address Line 1 ( ) -Fax Address Line 2

City, State, Zip

Dental Insurance Information

Dental Insurance Carrier: Membership ID #:

Employer Providing Insurance: Member Services Phone ( )

-Parent/Guardian Signature: Parent/Guardian Signature: Center Staff Signature:

Child Name:

Parent/Guardian Consents

Parent/Guardian Consent to Leave the Premises

Date:

Parent/Guardian Consent for Photography/Video of Child or Parent/Guardian

Date:

Registration Agreement

I understand and agree to the following:

I give permission for my child to leave the Center for exercise and educational purposes with Bright Horizons staff

Back-Up Care Advantage Program

Parent/Guardian Consents and Registration Agreement

1. Completion of Registration; Information; Payments. Registration must be fully completed prior to my using the Center. I will notify Bright Horizons and update all medical, family and other information previously provided as part of the registration of my child. Medical, family and other information may be shared among Bright Horizons child care centers where necessary for registration Additional registration information or materials may be needed to comply with local licensing requirements Where

yes no (please circle)

This page is only required for those families who will be attending a Bright Horizons center

yes no (please circle) Parent/Guardian Signature:

I give permission for my child to be photographed and videotaped for use by or on behalf of Bright Horizons for educational, training, curriculum, marketing and similar purposes.

Parent/Guardian Signature:

Date:

Date: Parent/Guardian Signature:

4. Release of Bright Horizons. In consideration of the registration of my child, I release Bright Horizons Family Solutions, Inc., Bright Horizons Children’s Centers, Inc., and their related companies, directors, officers, employees and agents, from any claims, losses, damages or costs (including attorneys’ fees) caused by or arising from my child’s registration, use of the Center, or participation in the programs and activities conducted by Bright Horizons other than to the extent caused by the negligent or willful misconduct of Bright Horizons Family Solutions, Inc., Bright Horizons Children’s Centers, Inc., and their related companies, directors, officers, employees and agents.

3. No Employment. I will not solicit, employ or enter into any contract with any employee of Bright Horizons to perform child care or similar services under any circumstances without the express consent of Bright Horizons. If I employ or contract with any employee of Bright Horizons or person who within one year of the date of such employing or contracting was employed or under contract with Bright Horizons, I will pay Bright Horizons a placement fee of $5,000.

2. Parent Handbook; Policies and Procedures; Use of Center. I have received, reviewed and understand the Parent Handbook and related information concerning the Center and the backup child care services provided by Bright Horizons. I will use the Center in accordance with the terms of the Parent Handbook and Bright Horizons policies and procedures made available at the Center. Use of the Center and the backup child care services may be denied in the event I do not comply with the terms of this Agreement, or when determined by Bright Horizons to be in the best interests of my child or the children using the Center. The availability of the Center and the backup child care services are subject to change at any time.

registration. Additional registration information or materials may be needed to comply with local licensing requirements. Where applicable, all registration fees and/or per-use fees (co-payments) must be paid in connection with the registration of my child and use of the Center.

Parent/Guardian Signature:

5. Release of Employer. My employer has engaged Bright Horizons to provide backup child care services as a convenience for my employer’s employees and other participants. My employer is not responsible for the Center or the backup child care services provided by Bright Horizons. In consideration of the registration of my child, I release my employer, and its directors, officers, employees and agents, from any claims, losses, damages or costs (including attorneys’ fees) caused by or arising from my child’s registration, use of the Center, or participation in the programs and activities conducted by Bright Horizons.

GROUP CHILD CARE AND SCHOOL AGE CHILD CARE

CHILD'S ENROLLMENT FORM

Program: Group Child Care: School Age Care:

Child's Name: Eye Color: Skin Color:

Home Address: Hair Color: Height:

Telephone: Sex: Weight:

Date of Admission: Age at Admission:

Date of Birth: Primary Language:

Identifying Marks: Allergies / special diets:

PARENT/GUARDIAN INFORMATION:

Parent/Guardian Name: Parent/Guardian Name:

Relationship to child: Relationship to child:

Home Address: Home Address:

Home Telephone #: Home Telephone #:

Bus. Name: Bus. Name:

Bus. Address: Bus. Address:

Bus. Telephone #: Bus. Telephone #:

Hours at Work: Hours at Work:

ADDITIONAL INFORMATION: Child's Physician/Clinic:

Address: Phone:

Chronic health conditions:

Special limitations or concerns:

SCHOOL AGE ONLY

Current School: School Address:

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: ____________

Parent/Guardian Signature Date

Page 1 of 2 GCCDevelopmentalHistotry20050701

DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION

Regulations for licensed child care facilities require this information to be on file to address the needs

of children while in care.

CHILD'S NAME ___________________________________ DATE OF BIRTH _____________

*Note: Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child.

DEVELOPMENTAL HISTORY

Age began sitting ________ crawling ______ walking _________ talking ____________

*Does your child pull up? ________ *Crawl? ______ *Walk with support? _______

Any speech difficulties?

Special words to describe needs

Language spoken at home _______________________ *Any history of colic? __________________

*Does your child use pacifier or suck thumb? _____________ *When? _______________________

*Does your child have a fussy time? ____________________ *When? _______________________

*How do you handle this time?

HEALTH

Any known complications at birth?

Serious illnesses and/or hospitalizations:

Special physical conditions, disabilities:

Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions:

Regular medications:

EATING HABITS

Special characteristics or difficulties:

*If infant is on a special formula, describe its preparation in detail

Favorite foods:

Foods refused:

* Is your child fed held in lap?

High chair?

* Does your child eat with spoon?

Fork?

Hands?

TOILET HABITS

*Are disposable or cloth diapers used?

*Is there a frequent occurrence of diaper rash?

*Do you use: oil

powder

lotion

other

*Are bowel movements regular?

how many per day?

*Is there a problem with diarrhea?

constipation?

*Has toilet training been attempted?

*Please describe any particular procedure to be used for your child at the center

What is used at home? pottychair? _______ special child seat? _________ regular seat? _________

How does your child indicate bathroom needs (include special words): _________________________

Is your child ever reluctant to use the bathroom? ___________________________________________

Does the child have accidents? _________________________________________________________

Page 2 of 2 GCCDevelopmentalHistotry20050701

SLEEPING HABITS

*Does your child sleep in a crib? ________ Bed? ________

Does your child become tired or nap during the day (include when and how long)? ______________

_________________________________________________________________________________

.

Please note: The American Academy of Pediatrics has determined that placing a baby on his/her

back to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and

unexplained death of a baby under one year of age. If your child does not usually sleep on his/her

back, please contact your pediatrician immediately to discuss the best sleeping position for your

baby. Please also take the time to discuss your child’s sleeping position with your caregiver

When does your child go to bed at night? ______ and get up in the morning? __________________

Describe any special characteristics or needs (stuffed animal, story, mood on walking etc) ________

SOCIAL RELATIONSHIPS

How would you describe your child:

Previous experience with other children/day care:

Reaction to strangers:

Able to play alone:

Favorite toys and activities:

Fears (the dark, animals, etc):

How do you comfort your child:

What is the method of behavior management/discipline at home:

What would you like your child to gain from this childcare experience?

DAILY SCHEDULE: Please describe your child's schedule on a typical day.

*For infants, please include awakening, eating, time out of crib/bed, napping, toilet habits, fussy time,

night bedtime, etc.

Is there anything else we should know about your child?

GCCSACCEmergencyCardInformation20050701

EMERGENCY

CARD INFORMATION

Child's Name:____________________________ Date of Birth:____________________________

Child's Home Address:________________________________________________________

_________________________________________ Phone: ___________________________

INSTRUCTIONS TO REACH PARENT/GUARDIAN

1.__________________________________________________________________________ (Name, Address, Phone #)

2.__________________________________________________________________________ (Name, Address, Phone #)

PEDIATRICIAN OR SOURCE OF HEALTH CARE

1. _________________________________________________________________________ (Doctor's Name, Address, Phone#)

EMERGENCY CONTACT PERSON(S)

1. _________________________________________________________________________ (Name, Address, Phone #)

2. _________________________________________________________________________ (Name, Address, Phone #)

MEDICAL EMERGENCY TREATMENT

I hereby give _________________________________________________________________ (Name of program)

permission to administer basic first aid and/or CPR to my child _________________________ (Name)

and/or take my child _______________________________, to a hospital for medical (Name)

treatment when I cannot be reached or when delay would be dangerous to my child's health.

______________________________________ ___________________________ (Parent Signature) (Date)

INSURANCE INFORMATION (OPTIONAL)

Company Name:________________________________ Policy #______________________________ Participating Hospital:_________________________________________________________________ Special Instructions:___________________________________________________________________

GROUP CHILD CARE AND SCHOOL AGE CHILD CARE FIRST AID AND EMERGENCY MEDICAL CARE

CONSENT FORM 102 CMR 7.09(3)

Child's Name: _______________________________ Date of Birth: ___________________

I authorize staff in the child care program who are trained in the basics of first aid to give my child first aid

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 Number: ____________________

Child's Allergies: ___________________________________________________________________

Chronic Health Conditions: ___________________________________________________________

Emergency Contacts (In order to be contacted)

1.

Name:

Address:

Relationship to Child:

Phone #:

Do you give permission for child to be released to this person? Yes

No

2.

Name:

Address:

Relationship to Child:

Phone #:

Do you give permission for child to be released to this person? Yes

No

3.

Name:

Address:

Relationship to Child:

Phone #:

Do you give permission for child to be released to this person? Yes

No

Health

Insurance

Coverage:

Policy

#:

Parent(s)

Name:

Phone(w)

Phone

(h)

Parent(s)

Name:

Phone(w)

Phone

(h)

Parent/Guardian

Signature

Date

SACCOffSiteActivitiesPermission20050701

PROGRAM YEAR _________

OFF-SITE ACTIVITIES PERMISSION FORM

Section 7.34(5)(c)

SACC Program: __________________________________________________

Address: __________________________________________________

__________________________________________________

CHILD'S NAME: __________________________________________________

I____________________________________, give permission for my child to participate (Parent/Guardian's name)

in all of the regularly scheduled on-going activities located at the following off-site facilities:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

The program will provide in writing a list of scheduled activities.

________________________________________ ______________ (Parent/Guardian Signature) (Date)

GCCPhysicianStatment20050701

(Child's Name)

is enrolled in an early childhood program licensed by the Department of Early Education and Care. The Department of Early Education and Care’s regulations require at the time of admission a written statement from a physician as evidence of each child's annual physical examination, immunizations and lead screening in accordance with Department of Public Health's recommended schedules. A prompt response is appreciated.

Evidence of a physical exam is valid for one year from the date the child was examined and must be renewed annually thereafter.

IDENTIFICATION

Name of Child: ______________________________________ Date of Birth: ___________________

Address: ________________________________________________ Phone # ____________________

Name of Parents: _____________________________________________________________________

Address: ____________________________________________________________________________

Date of Examination of Child: ___________________________________________________________

What is your opinion concerning the child's general health and appearance:

___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

Has this child been screened for lead poisoning? Yes ________ No _________ If Yes, date screened: _______________

Does this child have any disabilities or chronic medical problems (allergies, limited vision, etc.) which require special consideration or care by the child care provider? If so, please detail below:

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Physician's Signature: __________________________________________________________________ Date: _________________ Comments: ____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Please return to Program: _____________________________________

_____________________________________ _____________________________________

Massachusetts Department of Public Health

CERTIFICATE OF IMMUNIZATION

Name:

Date of Birth: Sex: 0 female o male

If combination vaccine is administered, please indicate vaccine type (e.g., DTaP-Hib, etc.)

Vaccine DateNaccine Type Vaccine DateNaccine Type Hepatitis B 1 Haemophilus 1

(e.g., HepB, HepB-Hib, OTaF'-HepB-IPV) 2

influenzae type b (e.g.,

Hib, HepB-Hib, DTaP·Hib) 2

3 3

4 4

Diphtheria, ₁ Measles, Mumps, 1

Tetanus, Pertussis -. (e.g., OTaP, DT, 2 Rubella (MMR) 2 DTaP-Hib, ₃ Varicella ₁ OTaP-HepB-IPV, Td, Tdap) 4 (Var) 2 5 Meningococcal ₁ 6 Conjugate (MCV4) or Polysaccharide (MPSV4) 2 Polio ₁ Hepatitis A 1 (eg,IPV, DTaP-HepB-IPV) 2 (HepA) 2 .. _­ 3 Pneumococcal Polysaccharide 1

4

_(PPV23) 2 5 Influenza ₁ Pneumococcal Conjugate (PCV7) 1 Inactivated (Intramuscular) or Live (Intranasal) 2 2 3 3 Other: 4

Serologic Proof of Immunity Check One Test (ifdone) Measles Mumps Rubella Varicella' Hepatitis B Date ofTesl I I I I I . I I I I I Positive Negative

, Must also check Chickenpox History box.

Chickenpox History

D

Check the box if this person has a p~.ysician-certified reliable history of chickenpox.

Reliable history may be based on:

• physician interpretation of parenUguardian description of chickenpox

• physical diagnosis of chickenpox, or • serologic proof of immunity

I certify that this immunization information was transferred from the above-named individual's medical records.

Doctor or nurse's name (please print): Date:

Signature:

Facility name: