Back-Up Care Advantage Program Registration Materials

Transcription

1 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

2 Registration Checklist 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) Connecticut - Child Health Record (one for each child to be registered - form must be completed by the child's physician) *Any photograph is acceptable (copy of drivers license or passport, family photo etc.) as long as the required parties are identified and the photograph is clear.

3 Child Registration Information Child Nickname: Child Date of Birth: ( / / ) (mm/dd/yyyy) Child Gender: Male (please circle) Female 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 Center Staff Signature:

4 )

5 Back-Up Care Advantage Program Parent/Guardian Information Form 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 listed on the child's file. Parent/Guardian Information Parent/Guardian Name: Relation to Child: Employer (Company Name): Cell Phone Work Address Work Phone & Ext Home Address Home Contact Information Home Address Home Phone Work Contact Information (Required if applicable) Work Address Home City, State, Zip Work City, State, Zip Parent/Guardian Information Parent/Guardian Name: Relation to Child: Employer (Company Name): Cell Phone Work Address Work Phone & Ext Home Address Home Contact Information Home Address Home Phone Work Contact Information (Required if applicable) Work Address Home City, State, Zip Work City, State, Zip shaded information is required for full registration and use of a back-up child care program

6 Parent/Guardian Authorization for Release of Child and Emergency Medical Treatment 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. Parent/Guardian Authorization for Release of Child: I authorize center staff to contact and/or release my child to the following representative(s) designated by me for this purpose: Please provide contact information for authorized non-parent/guardians on the Authorized Non-Parent/Guardian Information Form Parent/Guardian Authorization for Emergency Medical Treatment: I understand that center staff is trained in basic f irst aid and CPR. I authorize center staff to administer first aid to my child for minor injuries or illnesses as appropriate and to notify me of any actions taken. For all other conditions requiring emergency medical treatment, center staff will attempt to contact me as the nature of the emergency permits. If I cannot be reached, I authorize center staff to contact the following representative(s) designated by me to act on my behalf for this purpose. If my representative cannot be reached, I authorize center staff to transport my child to a local hospital or other medical facility and obtain any necessary medical treatment at my expense. Please provide contact information for aut horized non-parent/guardians on the Authorized Non-Parent/ Guardian Information Form Center Staff Signature:

7 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. 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 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 Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: Authorized for emergency medica l decisions? : Authorized for release of child?: yes no (please circle) yes no (please circle) Authorized Non-Parent/Guardian 3 Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: Authorized for emergency medical decisions?: Authorized for release of child?: yes no (please circle) yes no (please circle) Authorized Non-Parent/Guardian 4 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) shaded information is required for full registration and use of a back-up child care program.

8 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. 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 Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: 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 2 Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: 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 3 Work Phone: (if applicable) Cell Phone: (if applicable) Home Phone: Address City, State, Zip Authorized for emergency medical decisions?: Authorized for release of child?: yes no (please circle) yes no (please circle) shaded information is required for full registration and use of a back-up child care program.

9 Medical, Dental and Insurance Information Doctor Information Doctor/Clinic Name: Address Line 1 Doctor/Clinic Phone Address Line 2 Fax City, State, Zip Medical Insurance Information Medical Insurance Carrier: Membership ID #: Employer Providing Insurance: Member Services Phone ( ) - Hospital Information Affiliate/Preferred Hospital: Hospital Phone Dentist Information Dentist Name: Address Line 1 Dentist/Clinic Phone Address Line 2 Fax City, State, Zip Dental Insurance Information Dental Insurance Carrier: Membership ID #: Employer Providing Insurance: Member Services Phone shaded information is required for full registration and use of a back-up child care program. Center Staff Signature:

10 Parent/Guardian Consents and Registration Agreement This page is only required for those families who will be attending a Bright Horizons center Parent/Guardian Consents Parent/Guardian Consent to Leave the Premises I give permission for my child to leave the Center for exercise and educational purposes with Bright Horizons staff yes no (please circle) Parent/Guardian Consent for Photography/Video of Child or Parent/Guardian 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. yes no (please circle) Registration Agreement I understand and agree to the following: 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 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. 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. 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, 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. 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.

11 State of Connecticut Early Childhood Health Assessment Record To Parent or Guardian: In order to provide the best experience, early childhood providers must understand your child s health needs. This form requests information from you (Part I) which will also be helpful to the health care provider when he or she completes the health evaluation (Part II). State law requires complete primary immunization and a health assessment by a legally qualified practitioner of medicine, an advanced practice registered nurse, a physician assistant or the school medical advisor prior to entering an early childhood program in Connecticut. Please print Name of Child (Last, First, Middle) Social Security Number Birth Date Sex Address (Street) Race/Ethnicity American Indian White, not of Hispanic origin (Town and ZIP code) Asian Hispanic/Latino Black, not of Hispanic origin Other Parent/Guardian (Last, First, Middle) Home Phone Number Work/Cell Phone Number Early Childhood Program Program Phone Number Primary Health Care Provider Preferred Hospital Health Insurance Company/Number* or Medicaid/Number* * If applicable If your child does not have health insurance, call CT-HUSKY Part I To be completed by parent Important: Complete Part I before your child is examined. Take this form with you to the health care provider s office. Please check answers to the following questions in columns on the left. (Explain all yes answers in the space provided below.) Yes No 1. Do you have any concerns about your child s general health, development or behavior? 2. Has your child been diagnosed with any chronic disease asthma diabetes seizure disorder other 3. Does your child have any allergies (food, insects, medication, latex, etc.)? Please specify: 4. Does your child take any medications (daily or occasionally)? 5. Does your child have any problems with vision, hearing or speech (glasses, contacts, ear tubes, hearing aids)? 6. Has your child had any hospitalization, operation, major illness or injury, or significant accident? 7. In the last 12 months, has your child experienced any difficulty with wheezing or excessive night coughing? 8. In the last 12 months, has your child experienced any difficulty with excessive weight loss or weight gain, or excessive thirst or urination? 9. Has your child had a dental examination in the last 12 months? 10. Would you like to discuss anything about your child s health with the child care provider or health consultant/coordinator? Please explain any yes answers here. For illnesses/injuries/etc., include the year and/or your child s age at the time. I give permission for release of information on this form for confidential use in meeting my child s health and educational needs in the early childhood program. Signature of Parent/Guardian ED191 REV. 8/2004 C.G.S. Section 10-16q, , 19a-79(a), 19a-87b(c); P.H. Code Section 19a-79-5a(a)(2), 19a-87b-10b(2) Date To be maintained in the child s Health Record

12 Part II Health Evaluation To the Health Care Provider: Please complete all sections and sign. Explain any screenings required by age but not conducted. Child s Name Birth Date (mm/dd/yy) Date of History/Physical Exam (mm/dd/yy) LENGTH/HEIGHT WEIGHT WT FOR HT/BMI HEAD CIRCUMFERENCE 1 BLOOD PRESSURE 2 Vision 2 Test type: Hearing 3 Test type: Lead 4 Risk: Yes/No TB 4 Risk: Yes/No Urinalysis (UA) 4 Anemia 5 (HGB/HCT) Risk: Yes/No Developmental Assessment 6 Test type: IN/CM %ILE LB/KG %ILE %ILE IN/CM %ILE / Screening/Test Results Screening Test Result Date Abnormal/Comments Has this child received dental care in the last 12 months? 7 Yes No N/A * Chronic Disease Assessment: Yes No Asthma: mild moderate severe exercise induced unclassified Diabetes: Type I Type II Anaphylaxis: med. food insect latex Seizures: Type Other: Please specify Date of onset Minimum requirements: 1 Up to 2 years; 2 annual at 3 years; 3 annual at 4 years; 4 as needed; months; 6 each visit through 5 years; 7 annual at 2 3 years. Federal requirements (eg, Head Start, WIC) may vary. *Prior to Public School Entry: Same as above and Hgb/hct. Vaccine (Month/Day/Year) DTP DTP/Hib DTaP DT/Td OPV IPV MMR Measles Mumps Rubella HIB Hep B Varicella Disease Hx of above Immunization Record Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6 Other Vaccines (Specify) (Specify) (Date mm/yy) (Confirmed by) Exemption Religious Medical: Permanent Temporary Date Recertify Date Recertify Date Recertify Date This child has the following problems which may adversely affect his or her educational experience: Vision Auditory Speech/Language Physical Dysfunction Emotional/Social Behavior The child has a health condition which may require intervention at the program, e.g., seizures, allergies, asthma, anaphylaxis, special diet, long-term medication. Specify: PCV Pneumococcal conjugate vaccine Yes No This child has a medical or emotional illness/disorder that now poses a risk to other children or affects the child s ability to participate safely in the program. Yes No Based on this comprehensive history and physical examination, this child has maintained his/her level of wellness. The child may fully participate in the program. The child may fully participate in the program with the following restrictions/adaptation: (Specify reason and restriction.) I would like to discuss information in this report with the early childhood provider and/or health consultant/coordinator. MD/DO Signature of health care provider Name (Please type or print.) Phone number NP PA Address: Yes No Is this the child s Medical Home? Next Appointment (mm/yy): Next Immunization Appointment (mm/yy):