Emergency Information - littlesproutslcse.weebly.com€¦ · Web viewThe following days are prorated into your contract and are not charged for. The Center is closed on the following

Jan 2021

Registration PacketLittle Sprouts Learning Center, Inc.

500 4th Ave SWPO Box 412

Sleepy Eye, MN [email protected]

Center #: 507-794-8785 Director: Joy Wiese 507-829-3952

EMERGENCY INFORMATION FORM

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EMERGENCY INFORMATION

Child’s Name______________________________________________________ Date of Birth________________________________

Street Address_______________________________________________________________________________________________

City_______________________________________________________ State________________ Zip Code_____________________

Mother’s Name__________________________________________ Email address_________________________________________

Street Address_____________________________________________ Mailing Address_____________________________________

City_______________________________________________________ State_________________ Zip Code_____________________

Cell Phone___________________________________________ Home Phone_____________________________________________

Mother’s Place of Work________________________________________________ Work Phone______________________________

Father’s Name___________________________________________ Email Address_________________________________________

Street Address_______________________________________________ Mailing Address___________________________________

City______________________________________________________ State__________________ Zip Code_____________________

Cell Phone__________________________________________ Home Phone______________________________________________

Father’s Place of Work___________________________________________________ Work Phone____________________________

SOURCE OF REGULAR MEDICAL AND DENTAL CARE – REQUIRED FOR INFANTS TOO

Physician Name_______________________________________________________________________________________________

Health Care Facility Name____________________________________________________ Phone_____________________________

Health Care Facility Address_____________________________________________________________________________________

Health Concerns______________________________________________________________________________________________

Allergies_____________________________________________________________________________________________________

Dentist Name_________________________________________________________________________________________________

Dentist Office Address______________________________________________________ Phone______________________________

UNATHORIZED PERSON(S) – CANNOT PICK UP CHILD – LEGAL DOCUMENTATION IS REQUIRED

1) ____________________________________________ 2) _____________________________________________________

EMERGENCY CONTACTS – WHO MAY ALSO PICK UP MY CHILD FROM THE CHILD CARE CENTER

Name________________________________________________ Relation_______________________________________________

Address_____________________________________________________________________________________________________

Home Phone__________________________________________ Cell Phone______________________________________________

Name_________________________________________________ Relation______________________________________________

Address_____________________________________________________________________________________________________

Home Phone__________________________________________ Cell Phone______________________________________________

Name________________________________________________ Relation_______________________________________________

Address_____________________________________________________________________________________________________

Home Phone___________________________________________ Cell Phone_____________________________________________

Name_______________________________________________ Relation________________________________________________

Address_____________________________________________________________________________________________________

Home Phone___________________________________________ Cell Phone_____________________________________________

PICK UP AUTHORIZATION – FOLLOWING PEOPLE HAVE MY PERMISSION TO PICK MY CHILD UP FROM THE CENTER

Name______________________________________ Address____________________________________ Phone________________



Parent’s Signature__________________________________________________________ Date_______________________________

CLASSROOM INFORMATION

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CHILD’S INFORMATION

Child’s Name______________________________________________________ Date of Birth________________________________

Name Child prefers to be called__________________________________________________________________________________

Child’s

Address________________________________________________________________________________________________

Parent’s Phone Numbers 1)__________________________________________ 2)________________________________________

Child’s Race ________________________________________________

ESTIMATED HOURS AND DAYS OF THE WEEK YOUR CHILD WILL ATTEND THE CENTER

Monday_________________________________________ Tuesday_____________________________________________

Wednesday ______________________________________ Thursday____________________________________________

Friday ___________________________________________

ALLERGIES

Food Allergies________________________________________________________________________________________________

Signs of

Allergy________________________________________________________________________________________________

Treatment___________________________________________________________________________________________________

Medical Allergies______________________________________________________________________________________________

Signs of

Allergy________________________________________________________________________________________________

Treatment___________________________________________________________________________________________________

FAMILY BACKGROUND

Are there any family circumstances we need to know about to provide appropriate care for you child?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Are there any family traditions/customs you would like to share with us? ________________________________________________

Primary Language Spoken_________________________________________ Second Language Spoken_________________________

CLASSROOM INFORMATION

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HELPFUL INFORMATION

How do you comfort your child?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

What are your child’s favorite activities?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Does your child have an IEP? Learning or behavior delay or disorder that we need to be aware of? ____________________________

Is your child toilet trained? __________ Can they wipe by themselves? ____________________ Do they need help? _____________

How does your child indicate they have to use the bathroom?__________________________________________________________

Describe your child’s sleeping habits______________________________________________________________________________

Describe your child’s eating schedule_____________________________________________________________________________

What foods does your child not eat? ______________________________________________________________________________

How does your child communicate his/her needs to you?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Parent Signature_____________________________________________________ Date_______________________________

Teacher’s Signature___________________________________________________ Date_______________________________

Director’s Signature___________________________________________________ Date_______________________________

PARENT PERMISSIONS

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CHILD’S INFORMATION

Child’s Name________________________________________________________________ Date of Birth______________________

PERMISSIONS

I give my permission to Little Sprouts Learning Center Child Care staff to provide appropriate care for my child in an emergency, in

the event I can not be reached or am delayed.

Parent Signature______________________________________________________________ Date___________________________

I give my permission for my child to be photographed for center curriculum, projects, center promotions and newspaper articles.


I give my permission for the Little Sprouts Learning Center Health Care Consultant to review my child’s records concerning health

issues and to review immunization records when needed.


Your child will be participating in an assessment tool to measure his/her developmental progress. This is a non-standardized

assessment that measures developmental progress in children birth through Kindergarten. Parents will receive copies of this

information during parent conferences. I give my permission for my child to participate.

Parent Signature_____________________________________________________________ Date____________________________

I give my permission for sunscreen, bug spray, and oils to be applied to my child by the center staff according to manufacturer’s

instructions.


PARENT PERMISSIONS

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I give my permission for my child to participate in activities geared for my child, but asway from the childcare center. These activities

include walks around the neighborhood, trips to the parks, and pool. My child’s teacher will inform me in advance of field trips

beyond the immediate neighborhood.


Occasionally, students from the community attending school for early childhood have assignments to observe children in a childcare

setting We try to help as much as possible. We do not allow the child and the student to be alone together at any time. The student

will always be under direct supervision by a teacher in the classroom. This will not harm your child in any way or take away from

their experiences. It is just an educational opportunity for students who want to become an early childhood professional. I give my

permission for my child to be observed.


I give permission for my child to be transported in a vehicle by the center or another appropriate adult.

All children will be fastened in a safety seat or seat belt appropriate to their weight and age and will be installed and used in

accordance with the manufacturer’s instructions and state laws. A child will never be left unattended in a vehicle. Children will only

be transported after the approved passenger restraint training is completed.

I give permission for my preschool child to walk and/or participate in activities away from the center. These activities include

preschool at a different school. I understand my child will not be under the direct supervision of the staff at the center.


FAMILY CONTRACT

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EFFECTIVE CONTRACT DATE_____________________________________

PARENT INFORMATION

Mother’s Name_________________________________________________ Email address__________________________________

Home Address________________________________________________________________________________________________

List in order to call: 1) ______________________________________________ Type (Home, cell, work)_______________________

2) _______________________________________________ Type (home, cell, work)_______________________

3) _______________________________________________ Type (home, cell, work)_______________________

Father’s Name__________________________________________________ Email Address__________________________________

Home Address________________________________________________________________________________________________

List in order to call 1) _______________________________________________ Type (home, cell, work)________________________

2)_______________________________________________ Type (home, cell, work)________________________

3)_______________________________________________ Type (home, cell, work)________________________

This document serves to establish an agreement for the child/children listed below:

Age categories: Infant –6 weeks to 15 months, Toddler-16 months to 31 months, Preschool-33 months to 6 years or Kindergarten

1st Child Name____________________________ Date of Birth___________________________ Age Category__________________

2nd Child Name____________________________ Date of Birth___________________________ Age Category__________________

3rd Child Name____________________________ Date of Birth___________________________ Age Category__________________

Contracted Schedule: Check one ☐3 Days ☐4 Days ☐5 Days

3 and 4 Day contracts must be approved by the Center Director or Board of Directors – Priority will be given to 5 day contracts. Days and hours MUST be specified.

Schedule:

Care will be provided from __________________a.m. to _______________p.m. on the following days

Check all that apply for days of care:

☐Monday ☐Tuesday ☐Wednesday ☐Thursday ☐Friday

Contracted Days Infant Toddler Preschool6 weeks-15 months 16b months-32 months 33 months-kindergarten

5 Days $188 $163 $1534 Days $169 $146 $1373 Days $130 $113 $106

Contracted Amount Per Week________________________________________________________________

FAMILY CONTRACT

Summary of Policies Page 2 of 2

A deposit to secure your child’s spot is required upon completion of the registration process. This deposit is equivalent to the first week’s tuition rate and will be applied to your first week upon starting.

A one-time registration fee of $75 for each new family is required upon registration and admission. This registration fee will cover the review of the application to ensure all pieces of the application are completed and required documentation is in the child’s file.

A 10% sibling discount for the oldest child. Payment process: Automatic withdrawal is mandatory for all families. Automatic withdrawal payments will be taken out on

the Monday of services from your checking or savings account. Families receiving public assistance for childcare services must notify the Director immediately of any changes in the status

of this assistance. Failure to notify the Director within 5 business days will result in assessment of late charges and possible termination of services. Any tuition that is not covered by assistance, will be the responsibility of the family.

A $30 late fee will be charged each week for tuition payments not received or if there are insufficient funds in your account. This fee will be added weekly until payment is received in full.

The following days are prorated into your contract and are not charged for. The Center is closed on the following holidays: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the day after Thanksgiving and Christmas Day. IF Christmas Eve falls on a Monday, the Center will be closed, and the day will be considered a holiday. When Christmas Eve falls on a Tues, Wed, Thurs or Fri, the Center will be closed at 1:00 p.m. and the remainder of the day will be considered a holiday. The Center will be closed for 2 full days each year for cleaning. These days will be communicated with the holiday schedule prior to the start of the calendar year.

3-day & 4-day contracts must have specified days and hours. A 2-week written notice with payment and pre-approval is required to change your contract. A 2-week written notice with payment for the 2 weeks is required for withdrawal of a child. A child may be dismissed from the center if the welfare of themselves or others make it necessary and if all remedies to the

situation have been exhausted.

I acknowledge that I have read this contract and the Little Sprouts Learning Center Child Care Parent Handbook and understand my financial expectation and responsibilities.

Parent Signature___________________________________________________________ Date______________________________

Center Director/Board President Signature______________________________________ Date_______________________________

How did you learn about Little Sprouts Learning Center?

☐ Facebook

☐Website

☐ Word of Mouth

☐ Billboard

☐ Score Cards

☐ Other____________________________________________________________________________

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR WEEKLY PAYMENTS

I authorize Little Sprouts Learning Center and the financial institution listed below to initiate electronic debit

entries from my:

Please check one: ☐Checking Account ☐ Savings Account

I acknowledge that the origination of ACH transactions from my account must comply with the provisions of

the U.S. Law.

In the amount of $_________ every Monday of the week. This authority will remain in effect until a 2 week

written notification is given to Little Sprouts Learning Center, Inc. as the Financial Institution needs a

reasonable opportunity to cancel the debit transaction. In addition, the maximum amount that would be

allowed to be withdrawn from my account would be $_________________ (please add $50 to the contracted

amount to allow for fees if needed).

Financial Institution__________________________________________________________________________

City and State_______________________________________________________________________________

Bank Phone Number________________________________________________________________________

Name on Account (please print) _______________________________________________________________

Signature________________________________________________________ Date____________________

Phone Number____________________________________________________________________________

Transit Routing Number______________________________ Account Number__________________________

Please print routing and account number CLEARLY and please attach a VOIDED check for

verification of all financial institution information.

Note: Transaction on your bank statement will be listed as:

Little Sprouts Learning Center

500 4th Ave SW PO Box 412

Sleepy Eye, MN 56085

Phone: #507-794-8785

IMMUNIZATION FORMS AND HEALTH CARE SUMMARY

There tends to be confusion surrounding the next 2 documents, the first is the immunization form. This form is supplied by our licensing authority and while they allow us to accept a printout of your child’s vaccinations from the clinic, we must have signatures in the following.

If you have a medical exemption to any vaccinations, please have your child’s physician fill in Box 1 and Sign Box A.

If you have decided not to vaccinate your child because you have a conscientious objection to immunizations, box 1 B needs to be signed and notarized.

If your child has had the chicken pox disease, please complete and sign Box 2.

If you consent to our center sharing your child’s immunization record, please sign Box 3.

The next form is the Health Care Summary that, like the Immunizations Form, it is supplied to us by our licensing authority. This form must be filled out and signed by your child’s physician. We are not allowed to accept forms generated by a medical center.

Both forms need to be completed before we can enroll your child in Little Sprouts Learning Center Child Care Programs. If you have any questions, please feel free to call or email them to us.

HEALTH CARE SUMMARYMUST BE COMPLETED BY HEALTH CARE SOURCE

Date of Enrollment: _________________

NAME OF CHILD ___________________________________________________ Birth Date _________________________

ADDRESS _________________________________________________________ Telephone _________________________

PARENT(S) OR GUARDIAN ___________________________________________________________________

Date of last physical examination ____________ How long have you been seeing this child? ________________

How frequently do you see this child when he/she is not ill? _____________________________________________

Does this child have any allergies (including allergies to medications)? _____________________________________

Is a modified diet necessary? _____________________________________________________________________

Is any condition present that might result in an emergency? _____________________________________________

____________________________________________________________________________________________

What is the status of the child’s. . . Vision ________________________________________________

Hearing _________________________________________________

Speech __________________________________________________

Please list below the important health problemsFollowed Followed By Other Requires Special

Important Health Problems _By You__ Med Source (Name) Attention at Center____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Other information helpful to the child care program ______________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Signature of Health Care Source___________________________________________ Date_______________________

Address_______________________________________________________________ Phone_____________________

______________________________________________________________

MS-2083

PARENT ORIENTATION FORM

I, _______________________________________________________ have ben instructed, notified and understand the Little Sprouts Learning Center’s Program Policies and have been given a tour of the facility. I also understand that it is my responsibility to request further clarification from the Center Director or Board of Directors if I have any questions.

Parent Signature______________________________________________________ Date_________________

Director/Board President Signature_______________________________________ Date_________________

PERMISSION TO ADMINISTER

Child’s Name_______________________________ Parent’s Name____________________________NO

YES

PRODUCT Parent Provide

s

BRAND

Acetaminophen (following telephone permission from parent)

XAdhesive TapeAlcohol based hand sanitizerAllergy Medication XAntisepticBaby Lotion XBaby Oil XBaby Powder XBand-AidsBar SoapBurn/Sunburn Cream XChap Stick XCold Medicine XConditioner XCough Syrup XDiaper Cream XDiaper Wipes XEssential OilsFirst Aid CreamHydrogen peroxideInsect repellent XItching Cream XLiquid Hand SoapMenthol Rub XMoisturizing XNail PolishNail Polish RemoverRash ointment XShampoo XSunscreen XTeething ointment XOtherOther

A SEPARATE PERMISSION FORM IS REQUIRED FOR ALL PRESCRIPTION DRUGS.

Parent’s Signature_______________________________________________

Date_______________________________

Classroom Teacher’s Signature __________________________________

Date_______________________________

I give my permission to Little Sprouts Learning Center to administer the following products according to themanufacturer’s instructions or according to the attached instructions provided by the doctor or dentist. (9502.0435 Subpart 16,

F1)

RELEASE OF INFORMATION

I, _____________________________, do hereby give consent to Little Sprouts Learning Center, to use personal information about my child (ren) or I for reasons stated below:

☐Pictures

☐Newsletter

☐Posting on bulletins boards

☐Social Media

☐Other: ___________________________

The information to be released will be limited to:

☐Picture

☐Children’s Names

☐Children’s Birthdays

☐Parents Names

☐Parents Birthdays

☐Other: __________________________

I reserve the right to terminate this agreement at any time or at time of discharge from care.

Parents: _______________________________________Date:_____________

Provider: _______________________________________Date:____________

All About MeMy name is _____________________________________

My nickname is _________________________________

My mom’s name__________________________________

My dad’s name__________________________________

My siblings name & age___________________________

___________________________________________________________________________________________________________________________________________________Pet’s I have_____________________________________

Pet’s Name______________________________________

I live with my mom_____ dad_____ both_____

Favorite Color__________________________________

Favorite Food___________________________________

Favorite Snack__________________________________

Date filled out___________________

Keep for personal reference

Center Days Closed

*The following is a list of days the Center will be closed in 2021*

Friday January 1st – New Year’s Day

Friday February 26th - Closed for Cleaning

Friday March 19th – Closed for Staff Training

Monday May 31st – Memorial Day

Monday July 5th – Observation of Independence Day

Friday August 21st - Closed for Cleaning

Monday September 6th – Labor Day

Friday October 8th – Closed for Staff Training

Thursday November 25th - Thanksgiving

Friday November 26th – Day after Thanksgiving

Friday December 24th - Closes at 1:00p.m. -Christmas Eve

Keep for Personal Reference

ITEMS TO BRING FOR INFANTSPlease label everything with first and last name

Diapers Wipes Diaper Cream Ibuprofren/Tylenol ((will be stored in locked box) check expiration date!) 3 bottles Formula or breastmilk Sippy Cup for transitioning from bottle (360 cup only) 3 Extra outfits Light jacket for spring/fall Hats, gloves and warm jacket for cold weather Sunscreen (ages 6 months and up) – check expiration date! Bugspray Blanket for nap time (only 1 year and up) Pacifier if using one Family Picture

TODDLER ITEMS TO BRINGPlease label everything with first and last name

Diaper/pullups Wipes Ibuprofren/Tylenol ((will be stored in locked box) check expiration date!) 360 sippy cup – no spout cups allowed as we work on transitioning to regular cups 3 Extra outfits including underwear and socks Extra pair of shoes to be left at the center Reusable water bottle Naptime blanket (pillow is optional) Sunscreen – check expiration date! Bugspray Family picture

We do not allow toddlers to use bottles or pacifiers, if your toddler does use one, we will work with you on transitioning them off. This is for the health and safety of all the children in the classroom.

Please do NOT let your child bring toys and other personal items along to childcare, they will not be allowed to use them during childcare hours.

All children are REQUIRED to wear closed toe shoes during the day!


PRESCHOOL ITEMS TO BRING

Please label everything with first and last name

Pullups (if needed, we will be working on potty training) Wipes (if needed) Extra clothes: 2 pairs pants, 2 shirts, 2 underwear, 2 socks Pair of shoes to be left at the center and used for inside only. Sweatshirt in case your child gets cold Backpack Reusable water bottle Blanket for nap time (pillow is optional) Sunscreen – check expiration date!! Bugspray

Please do NOT let your child bring toys and other personal items along to childcare, they will not be allowed to use them during childcare hours.

All children are REQUIRED to wear closed toe shoes during the day!


Infant Classroom Schedule 6:30- 7:20 Arrival – Free Floor Play7:20-7:30 DIAPER CHANGES7:30 – 8:00 Fine Motor Skills-Tummy Time8:00 - 8:15 Story Time/Music8:15 – 8:45 Bottles/Snack Time/DIAPERS8:45 – 9:30 Quiet/Nap Time - Lights Off9:30-9:45 DIAPER CHANGES9:45 – 10:15 Outside Time/Walk10:15 – 11:00 ASL/Sensory Activities11:00 – 11:45 Feeding/Mealtime11:45 – 12:00 Indoor Play – Free Play12:00 – 2:00 Quiet Time/Nap Time -Lights Off2:00 – 2:15 DIAPER CHANGES2:15 – 2:45 Feeding/Mealtime2:45 – 3:15 Indoor Play3:15 – 4:00 Outdoor Play4:00 – 5:30 Diaper/Indoor Play


TODDLER CLASSROOM SCHEDULETIME ACTIVITY

6:30 – 7:30 Arrival/Free Play7:30-7:45 Diapering/Toileting

7:45 – 8:15 Table Activities/Sensory Table

8:15 – 8:30 Wash hands/ ASL8:30 – 8:45 Snack8:45 – 9:00 Diapering/Toileting/Hands9:00 – 9:20 Circle Time/Music9:20 – 9:45 Projects/Motor Skills9:45 – 10:00 Diapering/Toileting10:00 – 10:45 Outside/Walk10:45 – 11:00 Structured Play11:00 – 11:10 Story/Song Time11:10 – 11:40 LUNCH11:40 – 12:00 Diapering/Toileting/Cots out12:00 – 12:10 Story Time12:10 – 2:45 Nap Time2:45 – 3:00 Diapering/Toileting3:00 – 3:30 Snack/ Wash hands3:30 – 4:15 Outside/ Gross Motor4:15 – 5:30 Free Play/Goodbyes


PRESCHOOL CLASSROOM SCHEDULE

TIME ACTIVITY6:30 – 7:50 Arrival/Free Play7:50 – 8:15 Table Activities8:15 – 9:15 Snack/Work Time (Play)9:15 – 9:50 Circle Time/Gross Motor9:50 – 10:00 Bathroom/Wash Hands10:00 – 10:45 Outside/Walk10:45 – 11:00 Bathroom/Wash hands/Story or

Songs/Small Group/ Sensory11:00 (11:15) – 11:50 Lunch11:50 – 12:20/30 Clean up/Bathroom/Read books

on cots12:30 – 2:45 Nap/Rest Time2:45 – 3:30 Bathroom/Wash hands/Table

Activities/Snack3:30 – 4:15 Outside/Gross Motor4:15 – 5:30 Free Play/Goodbyes

**This schedule is subject to change due to the weather. On days we cannot go outside we do crafts, small group and sensory activities, or free structured play.*There are 2 mandatory bathroom breaks and both fall before we go outside. If we do not go outside, then they are not asked to go to the bathroom. Preschoolers should know when they have to go to the bathroom, therefore, the bathroom is available to them at any time of the day.

Documents

Emergency Information - littlesproutslcse.weebly.com€¦ · Web viewThe following days are prorated into your contract and are not charged for. The Center is closed on the following