REGISTRATION REQUEST FORM

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1 REGISTRATION REQUEST FORM PARENT S NAME ADDRESS DAY TIME PHONE# TOWN ZIP CODE ADDRESS: HOW DID YOU FIND OUT ABOUT TODAY S CHILD? PAYMENT METHOD: Private Pay CCIS Agency: Caseworker: My family needs care on: Monday Tuesday Wednesday Thursday Friday PLEASE CHECK ALL THAT APPLY The earliest my children will arrive is am. They will depart no later than pm. I am interested in Transportation: Yes Center child/ren will attend: OLDEST CHILD S NAME D.O.B Full Day Half Day He/She needs care: Before school only After school only Before & After School The school this child attends: SECOND OLDEST CHILD S NAME D.O.B He/She needs care: Full Day Half Day Before school only After school only Before & After School The school this child attends: THIRD OLDEST CHILD S NAME D.O.B He/She needs care: Full Day Half Day Before school only After school only Before & After School The school this child attends: Mail or bring form to: 21 W Baltimore Ave Lansdowne PA Fax: register@todayschild.us

3 CHILD ALLERGY INFORMATION You have indicated on your child s Emergency Contact / Parental Consent form that your child suffers from an allergy and/or allergic reaction. Please complete this form based on your child s individual needs. Please make sure that an adequate and up-to-date supply of all allergy medication is on hand at the center at all times in case your child has an allergic reaction while in our care. In addition to this form, parents must provide a copy of any additional physician's orders and procedural guidelines relating to the prevention and treatment of the child's allergy. Name of Child: Type of Allergy: Symptoms of an Allergic Reaction (hives, vomiting, swelling, etc.) Medication and dosage amount to be given in case of an allergic reaction: Medication Dosage Emergency Procedures to be taken (call parents, 911, doctor, etc.) Emergency numbers to be used: Mother or Guardian: Home Father: Home Work Work Cell Cell Alternative Emergency Contact: Name: Relationship: Home: Work: Cell: I hereby give permission for Today s Child Learning Centers, Inc. to post my child s allergy information in the center and administer any necessary medication. Parent s Signature

4 Dear Parents: The Department of Public Welfare, our licensing agency, requires that all children enrolled in a child care center receive health screenings and immunizations. Child care centers are required to obtain from the parent a child health report showing compliance within 60 days of enrollment. Health assessments must be received and updated in accordance with the following schedule: Infant: (6 wks 1 yr) Young Tod: (1 year olds) Older Tod: (2 year olds) Preschooler: (3 & 4 year olds) School Ager: The health report must be dated no more than 3 mos. prior to enrollment The health report must be updated every six months The health report must be dated no more than 6 mos. prior to enrollment The health report must be updated every six months The health report must be dated no more than 12 mo. prior to enrollment The health report must be updated every 12 months The health report must be dated no more than 12 mo. prior to enrollment The health report must be updated every 12 months The health report for a school age child must be dated in accordance with the requirements for medical exams for school attendance in the district in which the child resides The health report must be written and signed by a physician, physician s assistant or a CRNP. The signature must include the individual s professional title. The health report must contain the following information: A review of the child s health history A list of the child s allergies A list of the child s current medication and the reason for the medication An assessment of an acute or chronic health problem or special need and recommendations for treatment or services, including information regarding abnormal results of screening tests for vision, hearing or lead poisoning A review of the child s immunized status according to recommendations of the AICP A statement of the child s medical info pertinent to diagnosis and treatment in an emergency A statement that the child is able to participate in child care and appears to be free from contagion or comm. disease A statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted since the time of the previous health report required by this section A list of the dates the child was administered immunizations in accordance with the recommendations of the ACIP. In accordance with DPW regulations Today s Child may not allow a child who does not have a health report on file by the 60th day of enrollment to continue attending unless the parent provides written verification from a physician, physician s assistant, CRNP, the Dept. of Health or a local health department of the dates the child was administered immunizations in accordance with the recommendations of the ACIP. Today s Child is required to implement dismissal policies in accordance with the Department of Health regulation 28 Pa. Code relating to immunization requirements for children in child care group settings. You can find a copy of a health assessment for your physician to complete on our website.

5 CHILD HEALTH REPORT Parent/Provider fill in this part. (55 PA CODE , AND ) CHILD S NAME: (LAST) (FIRST) PARENT/GUARDIAN: DATE OF BIRTH: HOME PHONE: ADDRESS: COUNTY: WORK PHONE: CHILD CARE FACILITY NAME: FACILITY PHONE: I authorize the child care staff and my child s health professional to communicate directly if needed to clarify information on this form about my child. PARENT S SIGNATURE: DO NOT OMIT ANY INFORMATION This form may be updated by a health professional. Initial and date any new data. The child care facility needs a copy of the form. HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND DIAGNOSIS/TREATMENT IN EMERGENCY (DESCRIBE, IF ANY): NONE DESCRIBE ALL MEDICATION AND ANY SPECIAL DIET THE CHILD RECEIVES AND THE REASON FOR MEDICATION AND SPECIAL DIET. ALL MEDICATIONS A CHILD RECEIVES SHOULD BE DOCUMENTED IN THE EVENT THE CHILD REQUIRES EMERGENCY MEDICAL CARE. ATTACH ADDITIONAL SHEETS IF NECESSARY. NONE CHILD S ALLERGIES (DESCRIBE, IF ANY): NONE LIST ANY HEALTH PROBLEMS OR SPECIAL NEEDS AND RECOMMENDED TREATMENT/SERVICES. ATTACH ADDITIONAL SHEETS IF NECESSARY TO DESCRIBE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHILD, INCLUDING INDICATION OF SPECIAL TRAINING REQUIRED FOR STAFF, EQUIPMENT AND PROVISION FOR EMERGENCIES. NONE Parents may write immunization dates; health professional should verify and complete all data. IN YOUR ASSESSMENT, IS THE CHILD ABLE TO PARTICIPATE IN CHILD CARE AND DOES THE CHILD APPEAR TO BE FREE FROM CONTAGIOUS OR COMMUNICABLE DISEASES? YES NO IF NO, PLEASE EXPLAIN YOUR ANSWER: HAS THE CHILD RECEIVED ALL AGE APPROPRIATE SCREENINGS LISTED IN THE ROUTINE PREVENTIVE HEALTH CARE SERVICES CURRENTLY RECOMMENDED BY THE AMERICAN ACADEMY OF PEDIATRICS? (SEE SCHEDULE AT YES NO NOTE BELOW IF THE RESULTS OF VISION, HEARING OR LEAD SCREENINGS WERE ABNORMAL. IF THE SCREENING WAS ABNORMAL, PROVIDE THE DATE THE SCREENING WAS COMPLETED AND INFORMATION ABOUT REFERRALS, IMPLICATIONS OR ACTIONS RECOMMENDED FOR THE CHILD CARE FACILITY. VISION (subjective until age 3) HEARING (subjective until age 4) LEAD RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD S IMMUNIZATION RECORD IMMUNIZATIONS DATE DATE DATE DATE DATE COMMENTS HEP-B ROTAVIRUS DTAP/DTP/TD HIB PNEUMOCOCCAL POLIO INFLUENZA MMR VARICELLA HEP-A MENINGOCOCCAL OTHER MEDICAL CARE PROVIDER: SIGNATURE OF PHYSICIAN, CRNP OR PHYSICIAN S ASSISTANT ADDRESS: TITLE: PHONE: LICENSE NUMBER: DATE FORM SIGNED: CD 51 09/08

6 DISTANT EMERGENCY CONTACT & RELEASE FORM I, authorize Today s Child Learning Center to contact and release my child_, to the person(s) designated below in case of an emergency in which I cannot be contacted or located. This is in consonance with Today s Child Learning Center s Emergency Preparedness Plan. Please indicate a custodian who lives at least five miles away from our child care center and is not listed on your emergency contact form. Designated Custodian: Address Phone Number: Relationship to child: I do not have an emergency contact out of the state and/or immediate area. Parent/Guardian Signature Parent Address: Parent Home Phone: Parent Work Phone:_ Parent Cell Phone: Parent

7 INDIVIDUALIZED EDUCATION PLAN STATEMENT Today s Child works in cooperation with families and outside agencies to facilitate the provision of Early Intervention services for children in need. If your child does have an IEP or IFSP we would appreciate receiving a copy in order to more effectively meet your child s needs. Updated versions should be submitted as necessary. My child does not have an IEP or IFSP currently in place. My child has an IEP My child is currently receiving: My child has an IFSP Agency providing service Service provided Speech therapy On site Off site Physical therapy On site Off site Occupational therapy On site Off site Behavioral services On site Off site On site Off site On site Off site If services are to be provided off-site during the school day, who will be the transporting agency? What day of the week will this take place? Mon Tue Wed Thur Fri What time will your child be picked up? What time will your child return? Child s Name Parent s Signature

8 VIDEO AND PHOTOGRAPHIC PERMISSION FORM Child s Name Today s Child Learning Centers, Inc. has my permission to videotape and/or photograph my child for the purposes of Educational projects by the staff Staff training Newsletters Calendars Special Event postings at the center or on our website Signature of Parent and/or Guardian

To all Today s Child Parents and Guardians: This letter is to reiterate to you our concern for the safety and welfare of children attending Today s Child Learning Centers and to inform you that we

9 To all Today s Child Parents and Guardians: This letter is to reiterate to you our concern for the safety and welfare of children attending Today s Child Learning Centers and to inform you that we have Emergency Preparedness Plans in place for response to all types of situations. Depending on the circumstance of the emergency, we will use one of the following protective actions: Immediate Evacuation and Assembly Students are evacuated to an area that is a safe distance from the building. In-place Sheltering Sudden occurrences, such as weather or those related to hazardous materials, may dictate that taking cover inside the building is the best immediate response. Evacuation Total evacuation of the facility may become necessary. In this case, children will be taken to a relocation facility. Modified Operation May include cancellation/postponement or rescheduling of normal activities. These actions are normally taken in case of a winter storm or building problems (such as utility disruptions) that make it unsafe for children but may be necessary in a variety of situations. Method to Contact Parents In the event of an emergency, parents will be called, a note will be placed on the door, and radio/tv stations will be alerted to provide more specific information. Details will be posted and parents can check our website at for up to the minute announcements. Emergency ends/reuniting with children When the emergency ends, parents will be informed and reunited with their children as soon as possible. The contact methods listed above will be used to inform parents. We ask that you not call during an emergency. This will keep the main telephone line free to make emergency calls and relay information. The form designating persons to whom your child may be released will be used in situations such as those noted above. Please ensure that only those persons you list on the form can pick up your child. I specifically urge you not to make different arrangements during an emergency as it could create confusion and divert staff from their assigned emergency duties. A full copy of our Emergency Plan is located in the Parent Information area of the center. Please feel free to familiarize yourself with the document. Should you have any additional questions regarding our emergency operations please speak with the Director at your child s center. Listed below is a breakdown of the shelters and evacuation facilities for all our locations. CENTER LOCKED SHELTER INTERIOR SHELTER ASSEMBLY AREA OFF-SITE EVAC FACILITY Clifton Heights Colwyn Main Campus Media All classrooms st 1 floor storage room staff room & office Classrooms main hallway main hallway downstairs classes Hallways parking lot in rear parking lot behind church Pine St. & Maple Ave. back playground Aston Room 120 Library/Faculty Lounge Parking Lot on Side 300 E. Berkley Ave., Clifton Heights 235 Sharon Ave., Sharon Hill 250 Sharon Ave., Sharon Hill th 4 & Monroe St., Media 1 Neumann Drive Room 106 Library Parking Lot Near Field 1 Neumann Drive Gym Parking E Berkley Ave.,Clifton Hgts. Pennell Coebourn Lansdowne Darby Twp. Delcroft Harris K Center Sharon Hill Room 119 Classroom Room A4 Room 202 Guidance Office Faculty lounge Closet next to stage Community Cen Entertainment Rm Kitchen field near playground 2 Cambridge Road Brookhaven P hallways grass in front of the house 12 E Baltimore Ave, Lansdowne stage field 1 School Lane, Glenolden hallway outside of class parking lot on side 235 Sharon Ave., Sharon Hill interior hall/guidance Collingdale Park 800 MacDade Blvd., Collingdale interior hall/faculty lnge parking lot in front 801 Ashland Ave., Glenolden closet next to stage parking lot in back 235 Sharon Ave., Sharon Hill CHILD S NAME: I acknowledge receipt of info regarding the center s Emergency Preparedness Plan. _ Please print name here Please sign here

10 Dear Parents: Today s Child Learning Center s School Age Enrichment Program incorporates time each afternoon for homework assistance. We believe offering homework support in a structured environment with staff on hand to help and guide the students strengthens the learning process. Children will be given forty-five minutes to complete their homework. After the forty-five minutes is up children will be instructed to put their homework away to finish at home. As a parent, you have the choice to have your child participate in the homework program or save their homework to complete at home. Please indicate your choice at the bottom of this letter and return it to the Curriculum Director. If at any time during the school year you wish to change your choice, please notify the Director in writing. Thank you. Child s name School Homeroom Teacher Grade Room # Please check the appropriate box to indicate your preference I WANT my child to participate in the homework assistance program offered by Today s Child. I DO NOT WANT my child to participate in the homework assistance program offered by Today s Child. Parent s Signature

Child Name: Effective to Transport: MORNING Student transported to (School) from: (Center) by (Please indicated the time school begins).

11 Today s Child Learning Centers provides free transportation between our centers and local elementary schools. Parents that wish to take advantage of this service must complete this form, detailing their needs and giving permission for Today s Child to transport their child. Child Name: Effective to Transport: MORNING Student transported to (School) from: (Center) by (Please indicated the time school begins). Monday Tuesday Wednesday Thursday Friday AFTERNOON Student transported From (School) to: (Center) By (Please indicate the time school ends). Monday Tuesday Wednesday Thursday Friday MID DAY FOR KINDERGARTEN Student transported to (School) from: (Center) by (Please indicated the time school begins). Monday Tuesday Wednesday Thursday Friday Student transported From (School) to: (Center) By (Please indicate the time school ends). Monday Tuesday Wednesday Thursday Friday I hereby give Today s Child Learning Centers, Inc. permission to transport my child on a daily basis to and from the locations noted above. I understand that if there are any changes in the transportation needs of my child, or if my child will be absent on any given day I will notify Today s Child at least two hours prior to the scheduled transportation time. Parent/Guardian Signature Primary Telephone Number : Parent/Guardian (Print)

12 TODAY S CHILD LEARNING CENTERS INC. FAMILY HANDBOOK STATEMENT By signing below I acknowledge that I have read, understand and agree to abide by the policies, procedures and regulations set forth in Today's Child Learning Centers, Inc. Family Handbook. I agree to abide by the policies of both Today's Child Learning Center and the regulations of the PA Department of Human Services which governs child care centers in the Commonwealth of PA. In addition I agree to abide by the following policies: I will keep the Center Director informed and update any changes on the Emergency Contact Form as they occur. I will provide the Center Director with a working phone number where I can be reached as well as a back-up phone number in the event of an emergency. I agree to complete all forms necessary as required by the PA Department of Human Services and Today's Child Learning Centers, Inc. I will call the Center Director by 8:00am if my child(ren) will be absent or late. I will abide by the hours of contracted care as set forth in the Tuition Contract which was signed upon enrollment and provide the Center Director with two weeks advance notice should any changes in enrollment be needed. I will call the Center Director if someone other than myself is picking-up my child(ren) from care and have them provide photo identification upon arrival. I will clock my child(ren) in and out on the center's time clock each day upon arrival and departure. I will ensure that my child(ren) is escorted to their classroom and remain supervised by myself until they have been released into the care of their teacher. Upon departure, I will assume responsibility for the supervision of my child(ren) once they have been released from the care of their teacher. I will abide by the Illness Policies set forth in the Family Handbook and agree to keep my child(ren) home from care in accordance with the policies and guidelines set by the American Academy of Pediatrics and Today's Child Learning Centers, Inc. When requested I will provide a doctor's note upon return. I will abide by the Medication Policies of the center. I agree to provide the center with the required Health Assessments and follow the guidelines for periodic assessments as outlined by the American Academy of Pediatrics. I will ensure that my child(ren) has all of the necessary daily supplies as outlined in the Family Handbook in order for the staff to properly care for my child(ren). I agree to pay all fees on time as outlined on the Tuition Contract, including but not limited to tuition fees, late fees and bounced check charges. Parent/Guardian Signature 42

2018 TCDN SUMMER CLUB CAMP REGISTRATION FORM

2018 TCDN SUMMER CLUB CAMP REGISTRATION FORM Welcome to TCDN s 34th year of Summer Club! A fun filled camp for children entering grades 1-5, located on the grounds of the Swarthmore-Rutledge School. Summer