Hillside Community Preschool Child Enrollment Information Form

Hillside Community Preschool

2014 - 2015

Child Enrollment Information Form

Child Information

______________________________________________________________________________

_____________________________________________________________________________________________

Child’s Birth date Gender Child’s Home Language Child’s Race/Ethnicity

_____________________________________________________________________________________________

Child Lives With? Is there a court-ordered custody arrangement for this child? Yes No (If yes, please provide a copy.)

Class Enrolled in:

M-F (Born between Oct. 2, 2009-Oct. 1, 2011)

Family Information

______________________________________________________________________________

Parent or Guardian 1 Relationship to Child Email Address (one per family or address)

_____________________________________________________________________________________________

Home Address City State Zip Code

_____________________________________________________________________________________________

Home Phone Work Phone Cell Phone

_____________________________________________________________________________________________

Occupation Employer

_____________________________________________________________________________________________

Employer Address City State Zip Code

_____________________________________________________________________________________________ Parent or Guardian 2 Relationship to Child Email Address (if different from Parent 1) _____________________________________________________________________________________________

Home Address (if different from Parent 1) City State Zip Code

_____________________________________________________________________________________________

Home Phone Work Phone Cell Phone

_____________________________________________________________________________________________

Occupation Employer

_____________________________________________________________________________________________

Employer Address City State Zip Code

For Office Use Enrollment Date: Start Date: Registration Fee:

Payment Type: Check__ Cash__ Check Number:

Contact Information

Local contact person (e.g. friend, neighbor or relative) if parent is unavailable:

Please prioritize contacts in order of who should be called first. At least one must be listed as an Emergency contact.

_____________________________________________________________________________________________

Name Relation to Child OK to Pickup? Yes___ No___ Emergency Contact? Yes___No___

_____________________________________________________________________________________________

Phone Address City State Zip Code

_____________________________________________________________________________________________

Name Relation to Child OK to Pickup? Yes___ No___ Emergency Contact? Yes___ No___ _____________________________________________________________________________________________

Phone Address City State Zip Code

________________________________________________________________

Name Relation to Child OK to Pickup? Yes___ No___ Emergency Contact? Yes___ No___ _____________________________________________________________________________________________

Phone Address City State Zip Code

Medical Contact Information

______________________________________________________________________________

Child’s Physician Practice Name Phone

_____________________________________________________________________________________________

Physician’s Address City State Zip Code

_____________________________________________________________________________________________

Child’s Dentist Practice Name Phone

_____________________________________________________________________________________________

Dentist’s Address City State Zip Code

_____________________________________________________________________________________________

Hospital Phone

_____________________________________________________________________________________________

Hospital Address City State Zip Code

I agree to have my child examined by a physician annually and medical information returned to HCP for their files.

_____________ Initial

I give my permission to be listed in the HCP Directory:

_____________

I give my permission to receive e-mails concerning late starts, weather closures, reminders, newsletter, special events, and updates.

______________ _______________

Parent/Guardian #1intial Parent/Guardian #2 initial

I agree to comply with the program rules which are established and periodically amended by board members of Diakonia. I give permission to have my child receive emergency medical treatment as deemed necessary by the personnel at Hillside Community Preschool. I understand that while constant supervision of my child is provided by the staff of HCP, there is inherent risk of injury to my child from activities in the classroom, on the playground and in the building facilities of HCP. I accept this risk and on behalf of me and my spouse, if applicable, my child, and his/her and our heirs and legal representative, waive and release HCP from any and all claims (excluding only willful misconduct) for injuries sustained by my child while in the HCP program, and waive and release any claim for consequential and exemplary damages. I agree to indemnify and hold harmless and its agents and employees from any claim brought by or on behalf of my child, which is inconsistent with the above waiver and release.

_____________________________________________________________________________________________

Parent or Guardian Signature Date

Specific Health Concerns

______________________________________________________________________________

Child’s Name Date of Birth

Allergies: Yes___ No___ if yes, please specify. ___________________________________ Restrictions: Yes___ No___ if yes, please specify. ___________________________________ Operations/Serious Illnesses: Yes ___No___ if yes, please specify. _______________________ List any behavior or other special considerations:

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Health Insurance Coverage Information

Health Insurance? Yes ___No___

Address:_____________________________________________________________________________ Insurance Company ____________________________________________________________________ Phone Number ________________________________________________________________________ Policy Number ________________________________________________________________________

Group Number ________________________________________________________________________

If this information changes during the school year, I agree to inform Hillside Community Preschool of the changes.

_____________________________________________________________________________________

Parent/Guardian Signature Date

______If you do not wish to provide full health insurance information, please initial here.

Authorization for Access to Child Health Information

I, the parent/guardian of _______________________________ authorize the staff of Hillside

Community Preschool to have access to my child’s health information as provided to HCP (General Health Appraisal form, Immunization records, Health Insurance Coverage Information, specific health care plans). I understand that the records will be reviewed for completeness by office staff and HCP nurse consultant, and may be accessed other times through the school year by Colorado’s State Licensing Representative on an individual, as needed basis. I also authorize contact with my child’s physician via phone, fax or in writing as needed to continue medical care. Records are considered confidential material.

______________________________________________________________________________ Parent/Guardian Signature Date

Hillside Community Preschool

Emergency Medical Consent

Name: ______________________________ Birth Date:__________________ Sex: M F Address: __________________________________________________________________ Mother’s Name: _______________________ Tel(h) ____________ Tel(w) ___________

Tel(c) ____________

Father’s Name: ________________________ Tel(h) ____________ Tel(w) ___________ Tel(c) _____________

Emergency Contact Name: __________________________________ Tel ______________ Hospital: ______________________________________________ Tel ______________ Doctor: _______________________________________________ Tel ______________ Dentist: _______________________________________________ Tel ______________ Most Recent Tetanus Shot: __________________________________ MMR ____________ Allergies/Medications/Disabilities: ________________________________________________ Health Insurance Company: _________________________________

Health Insurance Card Number: ______________________________

HIB Vaccine: _________________________ Enrolment Date in Program: _____________

It is our policy to notify a parent when a child is ill or needs medical attention. Occasionally we cannot contact parents and we need to get immediate help for the child. Please sign the consent below so that we can take appropriate action on behalf of your child. We will take this signed consent with us to the emergency center.

I authorize the staff or person(s) in charge of HILLSIDE COMMUNITY PRESCHOOL, to call a physician, or summon an ambulance for emergency medical aid; should, in the opinion of the person(s) in

attendance, feel such services are required and I cannot be contacted by phone. If such emergency should arise, I shall be notified as soon as possible. I agree that any cost incurred for such services shall be the sole responsibility of myself.

HILLSIDE COMMUNITY PRESCHOOL

Volunteer Opportunities

2014-2015 School Year

Child’s Name________________________________

Child’s Class ________________________________

Class Days__________________________________

Email address________________________________

Phone Number _______________________________

Best way to reach you__________________________

( ) Help Organize Teacher Appreciation Week

( ) Help with Scholastic Book Orders

( ) Room Parent

( ) Organize meals for monthly staff meetings

( ) Special Visitor Willing to Share a Talent or Share the Tools of their

Occupation (e.g., construction, truck driver, hair stylist, dental hygienist,

police officer, fire fighter, chef, new baby, etc.)

(If you would like to be one of our special classroom visitors, please

indicate what you would like to share on the line below and we will touch

base to set up a time.)

I would like to visit the class and share:

Thank  you  for  volunteering  to  make  HCP  a  wonderful  place  for  families!!

Hillside Community Preschool

Dear Parents,

This form gives your child’s teacher permission to put sunscreen on your child.

The teacher will be provided with sunscreen to put on your child. If your child has any

skin allergies to sunscreen please let the director and your child’s teacher know and

provide your child’s sunscreen.

Child’s Name

Class

Teachers Names

I Do give my child’s teachers permission to put sunscreen on my child: Yes___ No___

I Do not give my child’s teachers permission to put sunscreen on my child: Yes __ No_

I will provide my child with his/her own sunscreen to be applied by my child’s

teachers (Please label child’s name on the sunscreen)

Parent/Guardian Sgnature

Date

Parent Release Form for Shutterfly

I, the undersigned, do hereby grant/deny permission to Hillside Community

PRESCHOOL to use the image of my

child,_________________________________, through photographs, images,

and/or video taken of my child for the class Shutterfly website.



Deny permission to use my child’s image at all.



Grant permission to use my child’s image in the Shutterfly class website

Parent/Guardians Signature

Date

I give permission for my child ___________________________, to be

photographed by Hillside Community Preschool staff for classroom

purposes. These photos may be displayed in the Hillside Community

Preschool classroom area, information board, and classroom projects. I

understand that no photos of my child will be published or distributed in

any way.

Parents/Guardian signature

Date

I do not grant permission for my child to be photographed by Hillside

Community Preschool staff for classroom purposes. My child’s photo may

not be displayed in the Hillside Community Preschool classroom area,

information board, or in classroom projects.

Parent’s/Guardian signature

Date

Permission to Participate in Walking Field Trips

I give my permission for my child ___________________________,

to participate in Walking Field Trips in the local area near Hillside

Community Preschool accompanied by the classroom teachers.

Parents/Guardian signature

Date

I do

NOT

give my permission for my child to participate in Walking Field

Trips in the local area near Hillside Community Preschool accompanied by

the classroom teachers.

PARENT please complete AND SIGN

GENERAL HEALTH APPRAISAL FORM

Child’s Name:_______________________________________________________ Birthdate: _____________________ Allergies:q _{None or Describe___________________________________________________________________________________________}

Type of Reaction ____________________________________________________________________________________________________

Diet: q _{Breast Fed} q _{Formula _______________________} q_{Age Appropriate}

q_{Special Diet ________________________________________________________________________________________________}

Sleep: Your health care provider recommends that all infants less than 1 year of age be placed on their back for sleep.

q _{Preventive creams/ointments/sunscreen may be applied as requested in writing by parent unless skin is broken or bleeding.}

I, ________________________________________ give consent for my child’s care health provider, school child care or camp personnel to discuss my child’s health concerns. My child’s health provider may fax this form (& applicable attachments) to my child’s school, child care or camp personnel. FAX #: _____________________________ DATE: _____________________________

Parent/Guardian Signature___________________________________________________________________

HEALTH CARE PROVIDER: Please Complete After Parent Section Completed

Date of Last Health Appraisal: _____________________________ Weight @ Exam: _______________________________________

Physical Exam: q_Normal q_Abnormal (Specify any physical abnormalities)_____________________________________________________

Allergies:q _{None or Describe__________________________ Type of Reaction ___}_______________________________________________ Significant Health Concerns: q_{Severe Allergies} q_{Reactive Airway Disease} q_Asthma q_Seizures q_Diabetes q_{Hospitalizations}

q_{Developmental Delays} q_{Behavior Concerns} q_Vision q_Hearing q_Dental q_Nutrition q _{Other ________________________________}

Explain above concern (if necessary, include instructions to care providers): ______________________________________________________

Current Medications/Special Diet: q None or Describe ______________________________________________________________________

Separate medication authorization form is required for medications given in school, child care or camp

For Fever Reducer or Pain Reliever

(

q_{Acetaminophen (Tylenol) may be given for pain or fever over 102 degrees every 4 hours as needed}

Dose ____________________ or see the attached age-appropriate dosage schedule from our office

OR q_{Ibuprofen (Motrin, Advil) may be given for pain or for fever over 102 degrees every 6 hours as needed}

Dose ____________________ or see the attached age-appropriate dosage schedule from our office

Immunizations: q_Up-to-Date q _{See attached immunization record} q_{Administered today: _____________________________________________}

**ONLY REQUIRED BY EARLY HEAD START AND HEAD START PROGRAMS PER STATE EPSDT SCHEDULE**

** Height @ Exam _____ ** B/P _____ **Head Circumference (up to 12 months) _______ ** ** HCT/HGB _____ ** Lead Level q_{Not at risk or Level _____}

**TB q_{Not at risk or Test Results} q _Normal q _Abnormal

**Screenings Performed: q_Vision: q_Normal q_Abnormal q_Hearing: q_Normal q_Abnormal q_Dental: q_Normal q

Abnormal-Recommended Follow-up________________________________________________________________________________________

Provider Signature

Next Well Visit: q _{Per AAP guidelines* or} q _{Age__________}

This child is healthy and may participate in all routine activities in school sports, child care or camp program. Any concerns or exceptions are identified on this form.

_____________________________________________________

Signature of Health Care Provider (certifying form was reviewed) Date: _______________

Office Stamp

Or write Name, Address, Phone, #

The Colorado Chapter of the American Academy of Pediatrics (AAP) and Healthy Child Care Colorado have approved this form. 04/07

COLORADO LAW REQUIRES THAT THIS FORM BE COMPLETED FOR EACH STUDENT ATTENDING COLORADO SCHOOLS Name_________________________________________________________________ Date of Birth _______________________________________ Parent/Guardian __________________________________________________________________________________________________________

COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT—CERTIFICATE OF IMMUNIZATION

Vaccine Enter the month, day and year each immunization was given Hep B Hepatitis B

DTaP Diphtheria, Tetanus, Pertussis (pediatric)

DT Diphtheria, Tetanus (pediatric)

Tdap Tetanus, Diphtheria, Pertussis

Td Tetanus, Diphtheria

Hib Haemophilus influenzaetype b

IPV/OPV Polio

PCV Pneumococcal Conjugate

MMR Measles, Mumps, Rubella

Measles Measles

Mumps Mumps

Rubella Rubella

Varicella Chickenpox Healthcare Provider Documentation Date_{_________________________________} Lab Verification Date_{_________________________________} Vaccines recorded below this line are recommended. Recording of dates is encouraged.

HPV Human Papillomavirus Rota Rotavirus MCV4/MPSV4 Meningococcal Hep A Hepatitis A TIV/LAIV Influenza Other

THIS SECTION CAN BE COMPLETED BY CHILD CARE/SCHOOL/HEALTH CARE PROVIDER

A) Child Care Up to Date ______________________________________________________________

Up to date through 6 months of age for Colorado School Immunization Requirements Update Signature Date

B) Child Care Up to Date ______________________________________________________________

Up to date through 18 months of age for Colorado School Immunization Requirements Update Signature Date

C) Child Care/Pre-school/Pre-K* ______________________________________________________________

Up to date for Child Care/Pre-School/Pre-K for Colorado School Immunization Requirements Update Signature Date

D) Complete for K–5th Grade ______________________________________________________________

Up to date for K–5th Grade for Colorado School Immunization Requirements Update Signature Date

* If age 4 years and fulfills Requirements for Pre-School & Kindergarten, check BOTH Boxes C and D.

IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS MAY BE SUBJECT TO EXCLUSION FROM SCHOOL AND TO QUARANTINE.

SI SE PRESENTA UN BROTE DE LA ENFERMEDAD, ES POSIBLE QUE A LAS PERSONAS EXENTAS SE LES PONGA EN CUARENTENA O SE LES EXCLUYA DE LA ESCUELA.

MEDICAL EXEMPTION:The physical condition of the above named person is such that immunization would endanger life or health or is medically contraindicated due to other medical conditions.

EXENCIÓN POR RAZONES MÉDICAS:El estado de salud de la persona arriba citada es tal que la vacunación significa un riesgo para su salud o incluso su vida; o bien, las vacunas están contraindicadas debido a otros problemas de salud.

Medical exemptionto the following vaccine(s):

La exención por razones médicasaplica a la(s) siguiente(s) vacuna(s):

Hep B DTaP Tdap Hib IPV PCV MMR VAR

Signed (Firma) _______________________________________________________________ Date (Fecha) ______________________________

Physician (Médico)

RELIGIOUS EXEMPTION:Parent or guardian of the above named person or the person himself/herself is an adherent to a religious belief opposed to immunizations.

EXENCIÓN POR MOTIVOS RELIGIOSOS:El padre o tutor de la persona arriba citada, o la persona misma, pertenece a una religión que se opone a la inmunización.

Religious exemptionto the following vaccine(s):

Exención por motivos religiososde la(s) siguiente(s) vacuna(s):

Hep B DTaP Tdap Hib IPV PCV MMR VAR

Signed (Firma) _______________________________________________________________ Date (Fecha) ______________________________

Parent, guardian, emancipated student/consenting minor (Padre, tutor, estudiante emancipado o consentimiento del menor)

PERSONAL EXEMPTION:Parent or guardian of the above named person or the person himself/herself is an adherent to a personal belief opposed to immunizations.

EXENCIÓN POR CREENCIAS PERSONALES:Las creencias personales del padre o tutor de la persona arriba citada, o la persona misma, se oponen a la inmunización.

Personal exemptionto the following vaccine(s):

Exención por creencias personalesde la(s) siguiente(s) vacuna(s):

Hep B DTaP Tdap Hib IPV PCV MMR VAR

STATEMENT OF EXEMPTION TO IMMUNIZATION LAW

(DECLARACIÓN RESPECTO A LAS EXENCIONES DE LA LEY DE VACUNACIÓN)

Name_________________________________________________________________ Date of Birth _______________________________________ Parent/Guardian __________________________________________________________________________________________________________