Family Home Child Care Parent Handbook

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Sprouts


Family Home Child Care
Parent Handbook

Kaedra Jacober, Owner

Sprouts

2330 Delwood Ave



Durango, CO 81301

(970) 385-1951



kaedraj@hotmail.com

Dear Parents and Guardians:

Welcome to Sprouts Family Child Care. It is my goal to provide a safe, nurturing environment for children in a home setting with fun and learning.


My philosophy of child care is to provide an environment for the child:

  • With the feeling of home

  • Where learning is exciting and hands-on

  • That encourages problem solving

  • Where the child feels safe and happy

  • Where growth is positive and well-rounded

My philosophy of child care is to provide for the parents/guardians:



  • Open and honest communication about your child

  • Participation in child’s development

  • A place they feel comfortable leaving their child

My background gives me the foundation to fulfill my philosophy, including:



  • A Bachelors in Education with endorsements in Early Childhood and English Language Learning (ELL)

  • A Child Development Associate (CDA)

  • Five years experience as a preschool teacher

  • Experience as an infant teacher

  • Experience as a toddler teacher

  • Directing summer programs with multiple age groups

  • A parent of 4 children

My goals in caring for your child are to:

  • Encourage learning through hands-on activities guided by children’s interests


  • Provide a variety of activities promoting social interaction, problem solving, learning, and self-discovery

  • To promote good self-esteem and self awareness

Thank you for choosing Sprouts. I hope your experience here is a happy one; please feel free to talk with me anytime you have questions or comments. As a team, we can work together to provide a safe, fun environment for your child.


Sincerely,

Kaedra Jacober, Owner


From time to time, I may need to make changes to the parent handbook due to changing laws or changes at Sprouts. I reserve the right to change policies and this handbook. If changes have been made, you will get a new handbook and need to sign a new agreement.

Table of Contents
Introduction 6
Statement of Non-discrimination 7
Contact info for state and complaints 7
Admission and Enrollment 8

Ages of Children

Deposit

Waiting List



Mutual Performance Expectations Statement

Agreement

Discharge

Enrollment Forms


Operations 10

Weekly Schedule

Holidays and Vacations

Emergency/Substitute Care

Disciplinary Policy

Incident and Injury Reporting Policy

Health Policies and Procedures

Emergency Evacuation

Home Safety

Field Trip Safety

State Policies
Fees for Services 15

Fee Structure

Late Fees

Fees Due Date

Delinquent Policy

Discounts

Rate Change Evaluation

Table of Contents

Developmental Program 16

Program Description

Sign-in/Sign-out

Daily Activity Schedule

Appropriate Dress

Meals

Child Assessment


Appendix 20

Child Enrollment Record

Mutual Performance Expectations Statement

Child Introduction Form

Medical Record
Authorization for Medical Treatment

Emergency Contacts and Permission to Drop Off and Pick UP

Travel and Activity Authorization

Incident and Injury Report


Disciplinary Report

Sign-in/Sign-out

Calendar

Introduction


Program

At Sprouts, we strive to provide a happy, safe and fun home-environment where children grow and develop at their own pace through hands-on experiences.


At Sprouts, we believe:



  • Children should be in an environment where they feel safe and cared for

  • Learning should be a result of hands-on experience through a variety of developmentally appropriate activities.

  • Children should learn to interact socially with respect and care for others

  • Parents and providers should work together to provide a consistent and positive experience for the children.

Provider

I have a lot of experience with many different age groups from birth to junior high. I have worked in an infant room, as a toddler teacher, as a preschool teacher, and directed summer programs. While working as a preschool teacher I created the curriculum for the class and taught there for 5 years. I have my bachelors in Education with endorsements in Early Childhood and English Language Learning (ELL).

Business

Sprouts is a family home daycare licensed for six children and two school-aged children. Of the six children, two can be under the age of two. We also have an alternate license of six children with three under the age of two, but no more than two under the age of 12 months. And lastly a license permitting up to 4 children 0-3 with one provider and 8 children 0-3 with two providers.

Statement of Non-Discrimination

Sprouts accepts children of any racial, national, religious, ethnic origin, or ability level from all backgrounds, belief systems, family dynamics, and orientations. All acceptances are based on the ability to give proper care for the child.

Listed below is contact information for reporting suspected child abuse or complaints about licensed child care.

Contact information for State
Edyth Eberhart

licensing specialist with the Colorado Department of Human Services

(970) 564-4275

Edyth.Eberhart@state.co.us
Colorado Department of Humans Services

(303) 866-5958



www.cdhs.state.co.us/daycare

1575 Sherman Street 1st Floor

Denver, CO 80203-1714

Child Abuse reporting Agencies

La Plata County Department of Social Services

(970)382-6150

(970)274-2208 (fax)

mayerle@co.laplata.co.us

Lezlie Mayer, Director

1060 East Second Ave

Durango, CO 81301


La Plata County Police Department

(970)385-2900

Admission and Enrollment
Ages of Children

Sprouts is licensed to provide care for up to eight children depending on ratios UNDER 3 different license types:



  • Regular 6+ 2 license

    • 6 children, no more than two children under 24 months
    • Two school agers 5 years to 12 years during non school hours


  • 3 under 2 license

    • 6 children, no more than two children under 24 months

    • No additional school age children, school agers count within the 6

  • Infant and Toddler license

    • 4 children with one provider, 8 children with two providers

    • All children between birth and 3

Deposit


Sprouts reserves the right to require a deposit equal to one week fees prior to the first day of care.
Waiting List

Children will be placed on a waiting list for openings, on a first-come, first-listed basis. Openings will be filled from that list with preference for full time children.


Mutual Performance Expectations Statement

Parents are asked to provide the following supplies, which will be kept for your child’s use only:



  • Infants/toddlers

  • Toddlers and older

    • Change of clothes appropriate to weather

    • Multiple changes of clothes for those potty training

Blankets and other security items are welcome; however, please try to only bring toys your child would like to share with the other children.

Each family is asked to contribute one box of quality brand tissues (the softer the better when you are dealing with sensitive noses). Each family is also asked to contribute one refill package of wipes per month if your child is in diapers.

Admission and Enrollment

Agreement

I ask that you sign a formal agreement giving Sprouts permission to care for your child during the hours you specify. The agreement also indicates your willingness to abide by the policies set forth in this handbook.

Discharge

Parental Withdrawal

If the parent/guardian finds it necessary to withdraw a child from care, he/she must give a two week notice prior to withdrawal. The deposit, amounting to one weeks care will be kept if a parent/guardian neglects to provide a two week notice.
Termination by Provider

In the event it becomes necessary for me to give notice to a parent/guardian to stop caring for a child, I will give two weeks notice prior to ceasing care. In extreme circumstances I will be forced to end care without a notice. The following reasons would be extreme circumstances:



  • Child consistently physically or verbally harms other children

  • Parent/guardian routinely abuses drop off and pick up times

  • Parent/guardian does not pay for child care fees on time

Enrollment Forms

After a reservation has been made for your child, and registration fee has been paid, you must provide the following forms, blank forms are located in the appendix;


  • Child Enrollment Record

  • Mutual Performance Expectations Statement

  • Agreement

  • Child Introduction Form

  • Medical Record

  • Authorization for Medical Treatment

  • Emergency Contacts and Permission to Drop Off and Pick Up

  • Travel and Activity Authorization

  • Media authorization

Operations


Weekly Schedule

Sprouts is open Monday through Friday from 7:30 am to 5:30 pm. I expect a calendar to be filled out with times you will be bringing your child. If there are changes, I need to be informed immediately and a new calendar will need to be submitted. The times you list on your calendar will be what early and late fees are based off of.


Holidays and vacations

The following holidays will be observed:

  • New Year’s Day


  • Memorial Day

  • Independence Day

  • Labor Day

  • Thanksgiving Day

  • Christmas Day

I will also close some of the days surrounding New Year’s Day, Thanksgiving and Christmas depending on where they fall during the week.


I do expect you to pay full weekly dues for all weeks of the year including the time you take for personal or sick time. You are paying for your child’s spot at Sprouts. However, there are days surrounding the Thanksgiving and Christmas holidays that will not be charged for. A list of holiday dates of closure will be given at the beginning of the year.
Emergency / Substitute Care

To ensure Sprouts is open on all days other than those specified as holidays and possibly on those holidays as well, I will use substitutes. I will use substitute care should I become ill or be absent for a personal reason. I will only use substitutes who have experience with children and have undergone a background check. I will have them around the children occasionally so the children will be familiar with them.

Operations
Disciplinary Policy

At Sprouts we expect children to act with self control, respect for others, and display good listening. To help children reinforce these actions, I will:



  • Model behaviors I want to see in the children.

  • Establish clear, consistent, and simple limits.

  • Explain reasons for rules.

  • Remain positive in our approach.

When discipline is necessary, I will:



  • Redirect child’s attention to an acceptable action.

  • Explain the negative behavior and help child identify solutions.

  • Give a time-out—a time to cool off and change attitudes.

  • Give a miss-out—a lost privilege.

  • Send a report home to you explaining what happened. See the sample Disciplinary Report in the Appendix.

All discipline is given for the behavior not the child so that children know they are still cared for and not “bad” kids. Hugs and smiles always accompany discipline.

Incident and Injury Reporting Policy

When a serious incident involves a child at Sprouts, an incident report is made. This information is provided to the parent/guardian, licensing agency, and insurance company. The purpose of these reports is to inform and follow-up on actions taken concerning the incident. Incident reports are made for the following serious incidents:



  • Injuries involving serious accidents, falls or motor vehicles

  • Unexpected illness, contagious disease

  • Poisoning or medication error

  • Aggressive or unusual behavior


Under federal and state law, owners of family child care businesses are required to report any reasonable suspicion of child abuse, neglect, or sexual abuse. If I have a reasonable suspicion of abuse or neglect, I will call the state child abuse hotline and local authorities.

Operations


Health Policies and Procedures

First Aid Procedures



  • Red Cross first aid and poison center guidelines will be followed.

  • All providers are certified by the Red Cross in emergency care and CPR for infants and children as required.

  • A first aid kit is kept on premises.

  • Emergency numbers are available at all times.

  • Parents will be notified of accidents and an injury record is kept for each child.

Medical Emergencies



  • Immediate first aid will be given.

  • An ambulance will be notified as soon as possible.

  • Parents will be notified as soon as possible.
  • When parents are not available, emergency references will be called.


  • Parents are responsible for any expenses as a result of emergency room care, ambulance, or other medical treatments.

  • Hospitals for emergencies are Mercy Medical Center and Durango Urgent Care

Illness


Please keep your child at home if you feel they are too sick to be in child care. Some reasons for your child to be kept home or sent home are listed below.

  • Fever of 100 or higher

  • Excessive drainage from nose or eyes that is green in color

  • Complaining of aches

  • Unable to participate in daily activities

  • Unidentified rash

  • Throwing up more than one time or if accompanied by other symptoms

  • Diarrhea more than once or if accompanied by other symptoms.

  • If your child becomes ill during the day, you will be notified and expected to pick your child up as soon as possible.

  • If your child will be missing due to illness, please notify me by phone the previous evening or the morning of the day of absence.

Operations


Communicable Disease Prevention Reporting

  • Your child must be current in his/her immunizations

  • Each child will be observed daily for illness

  • Using individual bedding, towels, washcloths, and glasses will minimize the spread of infection.

  • Child care provider will wash hands before and after diapering, toileting, eating, handling, and preparing food, and handling contaminated materials.

  • Diapers will be changed regularly and immediately after a bowel movement. Bottoms will be thoroughly cleaned; diaper cream or ointment must be provided by parent and have a medical administration form on file.
  • Bedding will be laundered as needed or once a week.


  • Bottles and nipples will be washed in the dishwasher and rinsed again with hot water before filling.

  • A child with a communicable disease will be kept isolated from other children as much as possible. Communicable diseases will be reported to the Department of Health

Management of Medication



  • All prescribed medication must be labeled with child’s name and must be accompanied by written permission from the parent for dispensing.

  • Medications must be stored in the original containers as prescribed.

Emergency Evacuation


Fire

To reduce the threat of fire, smoke detectors are installed in each room and checked regularly to make sure they are in working order. In case of fire, the children will evacuate the house from the front or back door. Parents will be called immediately.


Severe Storms

In case of severe storms, children will be kept inside away from windows and parents will be called.


Operations


Home Safety

The following safety measures are frequently checked and guidelines followed to ensure a safe learning environment for the children at Sprouts.



  • Children are continually watched, and the home maintains the proper staff/child ratio as set out by the licensing regulations.

  • Community service and emergency numbers are posted on the fridge for quick access.

  • The outside play area is fenced and free of dangerous objects.

  • Child equipment and toys are safe and in working condition.

  • Smoke detectors are installed throughout the house and are in working condition.

  • Gates keep children out of more dangerous areas such as the kitchen.

  • First aid supplies are available and stocked.
  • Electrical outlets and power strips are covered with appropriate child proof equipment as well as cabinets holding dangerous items.


  • No poisonous plants are within reach of the children.

  • Cleaning supplies, medicines, other toxic substances, and sharp objects are kept in locked cabinets or out of the reach of children.

Field Trip Safety

There are times throughout the month, especially when we don’t have a full crew of children, we will take field trips to different places in Durango. Sometimes we will walk, but in the event we drive we will always use proper car seat and safety precautions. I will notify you of an upcoming activity and ask you to sign a permission slip. If we are going somewhere with an admission fee, I will ask for admission fees with your permission slip. I have listed some possible field trip destinations.


  • Children’s Museum

  • Mason Center

  • Various Parks around Durango

  • Fish Hatchery

Operations


Statement of Policies from State Rules and Regulations

  1. In the event of loss, or damage of provider’s belongings beyond normal use, parent will be charged with replacement cost.

  2. We have a variety of bottles and cups at various stages for transitioning children from breast or bottle to cup. The parent and provider will be in communication about the best way to accommodate the child.

  3. Toilet training is encouraged when the child is developmentally ready. The provider does not endorse pull-ups and encourages parents to move from diapers to underwear. Extra clothes should be provided by the parent for multiple changes throughout the day. Parents and provider will work together to create a plan for toilet training.

  4. There is no smoking allowed in or around the house. Children will not be exposed to 2nd hand smoke while in care.
  5. During emergency inside the home, children and provider will follow evacuation plan outside and across the street to the yard of 2331 Delwood Ave with emergency phone numbers.


  6. During emergency outside the home, doors will be locked, shades closed and children will be gathered in a room away from the window where the danger is.

  7. State Rules and Regulations are available online at http://www.cdhs.state.co.us/childcare/ChildCareRules.htm. Or you can purchase a copy from the local Social Services Department.

  8. Any information the provider receives about toy recalls, equipment recalls, or safety issues will be posted and anything in this house will be removed immediately.

Fees for Services


Fee Structure

This Fee schedule is effective January 1, 2014 December 31, 2014.

Birth - Two

Full Time- 4 or more days a week $165 per week

Part Time- 1-3 days per week $35 per day

Two – Five

Full Time- 4 or more days a week $150 per week

Part Time – 1-3 days per week $35 per day

Fees cover all basic supplies, two snacks and lunch. Parents are responsible for providing diapers, wipes, formula and other necessities for their child.
A registration fee of $100 reserves your spot.
Late Fees

Child care hours are from 7:30 am to 5:30 pm. Please submit your schedule accordingly. Late and early fees are based on the hours you set to have care. Late or early fees of $1 per minute will be charged for children dropped off early or picked up late. This fee is due immediately.


Fees Due Date

Weekly fees are due on Monday or your first day for the week.

Delinquent Policy

Fees not paid by the close of Monday are expected Tuesday when dropping your child off. If you have not paid by then, there will be a $15 late fee each day until paid. However, if you have not paid or made arrangements for payment by Thursday morning, your child will not be allowed to come back for care until all fees have been caught up with late fees. This means you would have to pay for the present week + late fees from Tuesday through the date paid and the following week.

Rate Change Evaluation

Rates are evaluated each October and parents/guardians are given at least six weeks notice of any changes. I reserve the right to change my rates and honor old rates for established customers.

Developmental Program
Program Description

Although we have a very tentative and rough schedule at Sprouts, we will incorporate major elements of physical, emotional, social, and mental development. There are certain elements of intelligent learning that I hope to capture almost every day. I have listed some of the ways I would like to structure activities to meet these goals. However, there will not be a very firm structure to the day. Our days will be lead by children interest and teachable moments. I feel, especially with young children, teachable moments are the key to inspiring young minds to learn.


Intelligences

  • Linguistic Intelligence

  • Musical Intelligence

  • Logical-mathematical intelligence

  • Spatial intelligence

  • Bodily-kinesthetic intelligence

  • Interpersonal intelligence

  • Intrapersonal intelligence

Different Learning Styles



    • Auditory Learners

    • Visual Learners

    • Hands-on Learners

Developmental goals



  • Social skills

  • Fine motor skills

  • Large motor skills

  • Mental development

Please feel free to visit your child at any time or just call and check in. If I do not answer please leave me a message and I will return your call as quickly as possible.

Developmental Program

Sign-in / Sign-out

Parents/guardians must sign their child in every day when dropping off and out every day when picking up. The sheet must be filled out completely with name of child, date, time, and a signature.

Daily Schedule

This schedule is very tentative as I explained in the program section. The activities will vary in length and type suiting the children and their needs that day.


7:30 to 8:10 Children arriving – free play

8:10 to 9:00 Activity indoors

9:00 to 9:15 Diapers, potty, wash hands

9:15 to 9:30 Snack

9:30 to 10:00 Circle time

10:00 to 10:50 outside (depending on the weather)

10:50 to 11:10 free play

11:10 to 11:15 wash hands for lunch

11:15 to 11:45 lunch time

11:45 to 12:00 Wash hands and faces, potty, change diapers

12:00 to 2:00 nap time

2:00 to 2:45 free play-kids getting up, potty, changing diapers

2:45 to 3:15 Outside

3:15 to 3:30 Snack

3:30 to 4:15 Inside activity

4:15 to 5:00 big time clean up!!

5:00 to 5:30 story time

Appropriate Dress

Children should wear casual, comfortable clothes for playing and appropriate for the season. Please send clothes for outdoor play as well. We will go outside unless the weather is extreme. Please dress children appropriately.

Developmental Program

Meals

I believe in healthy food and well- rounded meals. I try to buy as much whole grain, natural, organic and healthy food as possible. I do can and dry fruits, vegetables and jams every year and I include these in my meals. I participate in the Wildwoods Food Program and I follow their meal guidelines; the program was established to support healthy meals for children in childcare. I have pasted an excerpt from Wildwood of their meal expectations below. If you have any questions or concerns, please feel free to talk with me about it.



Breakfast for Children

 

 

 

Select all Three (3) Components for a reimbursable meal

 

 

 

 

 

 

 

Food Components

Ages 1-2

Ages 3-5

Ages 6-12*

1 milk

 

 

 

 Fluid milk                                  

1/2 cup

3/4 cup

1 cup

 

 

 

 

1 fruit/vegetable

 

 

 

 juice**, fruit and/or vegetable                    


1/4 cup

1/2 cup

1/2 cup

 

 

 

 

1 grains/bread***

 

 

 

 bread or                              

1/2 slice

1/2 slice

1 slice

 cornbread or biscuit or roll or muffin or

1/2 serving

1/2 serving

1 serving

 cold dry cereal or

1/4 cup

1/3 cup

3/4 cup

 hot cooked cereal or

1/4 cup

1/4 cup

1/2 cup

 pasta or noodles or grains

1/4 cup

1/4 cup

1/2 cup


 

 

 

 

* Children age 12 and older may be served larger portions based on their greater food needs. They may not be served less than the minimum quantities listed in this column.

 

 

 

 

** Fruit or vegetabe juice must be full strength and 100% juice

 

 

 

 

*** Breads and grains must be made from whole-grain or enriched meal or flour. Cereal must be whole grain, enriched, or fortified.




 




    Lunch or Supper for Children

 

 

 

Select all four (4) Components for a reimbursable meal

 

 

 

 

 

 


 

Food Components

Ages 1-2

Ages 3-5

Ages 6-12*

1 milk

 

 

 

 Fluid milk                            

1/2 cup

3/4 cup

1 cup

 

 

 

 

2 fruits/vegetables

 

 

 

 Juice**, fruit and/or vegetable           

1/4 cup

1/2 cup

3/4 cup

 

 

 

 

1 grains/bread***

 

 

 

 Bread or                    

1/2 slice

1/2 slice

1 slice

 cornbread or biscuit or roll or muffin or


1/2 serving

1/2 serving

1 serving

 Pasta or noodles or grains

1/4 cup

1/4 cup

1/2 cup

 

 

 

 

1 meat/meat alternate            

 

 

 

 Meat or poultry or fish**** or

1 oz.

1-1/2oz.

2 oz.

 alternate protein product or

1 oz.

1-1/2oz.

2 oz.

 cheese or

1 oz.

1-1/2oz.

2 oz.

 egg or                      

1/2

3/4

1

 cooked dry beans or peas or

1/4 cup

3/8 cup


1/2 cup

 peanut or other nut or seed butters or

2 Tbsp.

3 Tbsp.

4Tbsp.

 nuts and/or seeds***** or

1/2 oz.

3/4 oz.

1 oz.

 yogurt******

4 oz.

6 oz.

8 oz.

 

 

 

 

*Children age 12 and older may be served larger portions based on their greater food needs. They may not be served less than the minimum quantities listed in this column.

 

 

 

 

**Fruit or vegetable juice must be full-strength and 100% juice.

 

 

 

 

***Breads and grains must be made from whole-grain or enriched meal or flour. Cereal must be whole-grain, enriched, or fortified.

 

 

 

 

****A serving consists of the edible portion of cooked lean meat or poultry or fish.


 

 

 

 

*****Nuts and seeds may meet only one-half of the total meat/meat alternate serving and must be combined with another meat/meat alternate to fulfill the lunch or supper requirement.

 

 

 

 

******Yogurt may be plain or flavored, unsweetened or sweetened.

 














http://www.wildwoodonline.org/tp40/page.asp?ID=115359. accessed 10 November, 2008.
Appendix

Child Enrollment Record 22

Agreement 23

Child Introduction Form 24

Medical Record 25

Authorization for Medical Treatment 26

Emergency Contacts and Permission to Drop Off and Pick Up 27

Travel and Activity Authorization 28

Media Authorization 29

Incident and Injury Report 30

Disciplinary Report 31

Sign-in/sign-out Sheet 32

Calendar 33

Child Enrollment Record

Child’s Name__________________________________ Gender_____ Birthday__________________

Home Address_________________________________________ Home Phone____________________


Basic Information

Mother/Guardian’s Name______________________________ Home Phone___________________

Address_________________________________________________________________________________

Date of Birth___________________________ Employer________________________________________________Hoursfrom__________to________

Employer address_______________________________________ Work phone___________________
Father/Guardian’s Name_______________________________ Home Phone___________________

Address_________________________________________________________________________________

Date of Birth___________________________

Employer________________________________________________Hoursfrom__________to________

Employer address_______________________________________ Work phone___________________
Date Child Entered Care:________________________________________________________________

Date Child Left Care:____________________________________________________________________

Special Instructions:____________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Agreement

I have read and understand all papers given to me by my provider, and I agree to fulfill my responsibility as stated in those papers. When my child is ill, I understand and agree that he/she cannot be accepted into care. I understand the provider’s policies pertaining to the admission, care, and discharge of children. I agree to talk to my provider regularly about my child and work with my provider as a partner in the care of my child so that my child experiences consistency. I agree to work as a team with my family child care provider and respect each party’s child-rearing values.

Parent/guardian Signature_______________________________________________
Care Giver Signature______________________________________________________
Date__________________________

I have read and understand all papers given to me by my provider, and I agree to fulfill my responsibility as stated in those papers. When my child is ill, I understand and agree that he/she cannot be accepted into care. I understand the provider’s policies pertaining to the admission, care, and discharge of children. I agree to talk to my provider regularly about my child and work with my provider as a partner in the care of my child so that my child experiences consistency. I agree to work as a team with my family child care provider and respect each party’s child-rearing values.


Parent/guardian Signature_______________________________________________
Care Giver Signature______________________________________________________
Date__________________________

Child Introduction Form


It is very helpful to know some background information about your child so that we may become fast friends and the transition isn’t too difficult.
Is your child:

  • Shy?

  • Overactive?

  • Toilet trained?

  • Used to a daily nap(s)?

    • Specific time(s)?

  • Subject to temper tantrums?

Does your child:



  • Suck his/her thumb or pacifier?

  • Speak another languages or sign?

  • Have any fears?

  • Have nervous habits (ie. biting fingernails)?

  • Plays well with other children?

  • Had a traumatic experience (divorce, death in the family, move…)

  • Have siblings?

    • How many? (please list names and ages below)

Other information I should know or comments:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If this information changes at any time, please let me know so that I might provide excellent care for your child. This information is confidential and only used to adapt the environment and care for the child.
Signature of Parent/guardian_________________________________________________________Date__________
Medical Record
Name of Child__________________________________________________________________________

Date of Birth____________________________________________________________________________


Mother

Name___________________________________________________________________________________

Address_________________________________________________________________________________

Home Phone Number________________________ Work phone number______________________


Father

Name___________________________________________________________________________________

Address_________________________________________________________________________________

Home Phone Number________________________ Work phone number______________________


Physician

Name___________________________________________________________________________________

Address_________________________________________________________________________________

Phone Number__________________________________________________________________________


Immunization Type Date Given

DTP_____________________________________________________________


Polio_____________________________________________________________

MMR____________________________________________________________

Hepatitis B______________________________________________________

Haemophilus____________________________________________________

Chronic Illnesses Allergies Current Medication


  • ________________________
  • ________________________


  • ________________________

  • ________________________

  • _________________________

  • _________________________

  • _________________________

  • _________________________




  • _____________________

  • _____________________

  • _____________________

  • _____________________




Special Information:
Hospital Preference:_____________________________________________________________________
Dentist name and contact:_____________________________________________________________

Authorization for Medical Treatment


Sprouts has my permission to obtain emergency medical treatment for my child, ________________________________________________, when I cannot be reached or if a delay in reaching my child would be dangerous for him/her.
My insurance provider is__________________________________________________
Numbers or information pertaining coverage are__________________________ ____________________________________________________________________________
I understand that I assume all financial responsibility for any treatment or injuries sustained by my child while he/she is in care.
Signature of parent/guardian_____________________________ Date___________

Emergency Contacts and

Permission to Drop Off and Pick up
Name___________________________________________________________________________________

Address_________________________________________________________________________________

Relationship____________________________________________________________________________

Home Phone Number__________________________ Work Phone Number___________________

Name___________________________________________________________________________________

Address_________________________________________________________________________________

Relationship____________________________________________________________________________

Home Phone Number__________________________ Work Phone Number___________________

Name___________________________________________________________________________________

Address_________________________________________________________________________________

Relationship____________________________________________________________________________

Home Phone Number__________________________ Work Phone Number___________________


Name___________________________________________________________________________________

Address_________________________________________________________________________________

Relationship____________________________________________________________________________

Home Phone Number__________________________ Work Phone Number___________________

Travel and Activity Authorization
I give my permission for my child, ____________________________________, to leave Sprouts for supervised trips on foot or in a vehicle that is in safe and working condition and with working seat belts and car seats to special places such as:
Trips to Parks


  • The Children’s Museum

  • Fish Hatchery

  • Library

  • Other

Restrictions on such trips for my child include:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature of parent/guardian___________________________ Date_________________________

Media Authorization

I give my permission for my child, ____________________________________, to be involved in activities using multiple types of media such as television shows, video, music, computer websites and computer software. Only child appropriate media will be used. Below is a list of websites you can access at home with your children as well.

I do not want my child, ___________________________________, involved in activities using media. Your child will be offered an alternative activity while the other children are busy.


www.sheppardsoftware.com

www.ixl.com

www.starfall.com

www.childrensmuseum.org

www.familyfun.go.com

Incident and Injury Report

Name of Child__________________________________________________________________________

Date of incident or injury ______________________________________________________________

time of incident or injury______________________________________________________________

Incident or injury description____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Action Taken_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name of parent/guardian notified______________________________________________________

Person(s) who observed incident________________________________________________________

Comments____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

*Other children involved in the incident may not be named on incident report.

Disciplinary Report

Child’s Name_______________________________________________ Date_______________________

Location of child during discipline_____________________________________________________

Beginning time_____________________________________________

Reason________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other alternatives tried prior:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Observed Effect_________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________Staff implementing discipline:_________________________________________________________

Comments____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

From here…_____________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

Signature ___________________________________________________Date______________________

Parent/guardian signature__________________________________Date______________________


Sign-in/Sign-out


Date

Child’s Name

Time in

Parent Signature

Time out

Parent Signature


















































































































































































































































































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