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Start Date: ______________ Provider:____________________________
End Date: ______________
Childs Information:
Name:_________________________________ Sex: F / M D.O.B: (Month / Day / Year) ____________________
Language(s): ___________________________________ Phone Number: ________________________________
Address: __________________________________________________________________________________________
Email Address: _____________________________________________________________________________________*Allergy/medical Condition:_________________________________________________________________
Family Information: Living with Mom / Dad / Both / Other; ______________________________________________
Any Custody arrangements we should be aware of? Y / N If yes, please attach supporting documentation.
Main Caregiver: ________________________________ Phone Number: __________________________
Name: _______________________________________ Cell Number: ____________________________
*Location while child is at daycare __________________
*Employer/School: __________________________ *Address: ___________________________ Work/School phone: _______________________ Work Number:__________________________
Secondary Caregiver ____________________________ Phone Number: __________________________
Name: ________________________________________ Cell Number: ____________________________
Emergency contact and persons the child may be released;
Name:_______________________________________ Phone Number:__________________________
Relation:_____________________________________ Cell Number:____________________________
Name:_______________________________________ Phone Number:__________________________
Relation:_____________________________________ Cell Number:____________________________
Name:_______________________________________ Phone Number:__________________________
Relation:_____________________________________ Cell Number:____________________________
Persons listed above may be contacted when parent(s) and or caregiver(s) cannot be reached in an emergency situation, illness, or for any other serious circumstance.
SUPERVISION AGREEMENTGeneral Supervision
The child will be arriving at the home child care program via: ________________________.Once at the day care, the responsibility of
the child will be that of the Provider. At no time is the child allowed to leave the premises with anyone other than those listed in the
“Emergency contact, and persons the child may be released” unless authorization is received from the parent/guardian.
On the occasion where someone has arrived for the first time to pick up the child, identification must be shown to the provider
before the child is released from their care. (This includes relatives of the child whom the provider has not yet met.)
The child will be departing the home child care program via: ________________________. A parent or authorized person must
accompany the child into and out of the home each day and initial the attendance record for both arrival and departure.
An adult (18 years of age or older) must be present at all times to supervise the child, both indoors and outdoors.
Outdoor Supervision
The CCEYA requires that children are exposed to outdoor play for a minimum of two hours per day, weather permitting. This may
include walks and/or outings within your provider’s neighbourhood.
Your provider will make you aware of outdoor locations he/she frequents within their daily program plans.
In the event that a more extensive field trip is planned, you will be informed well in advance by your provider, to ensure proper
authorization. If you are uncomfortable with any planned field trip, you are not obligated to authorize for your child to take part.
Your child is never allowed to leave the provider’s location, with or without the provider or his/her staff, unless there has been
authorization from the parent/guardian regarding that specific day, and event. The provider is to also notify Jubilee office of any
trips outside the premises.
Every operator of a Private Home Day Care agency shall ensure that outdoor play in each location is supervised in accordance with
plans agreed upon by the parent, provider and the Home Child Care Consultant.
0-6 years of age
I agree that the Provider must be physically present at all times when my child is sleeping or playing outdoors Y / N
6 years of age or older
The extent of supervision of outdoor play must be agreed upon based upon maturity of the individual child and the physical
environment. Please take this into consideration when requesting any of the following arrangements;
I agree that the provider must be physically present at all times when my child is playing outdoors. I agree that my child may be supervised by the Provider from a window when playing outdoors.
YY
NN
I agree that my child may walk to and/or from school without the physical presence of the Provider, BUT MUST BE VISABLE to the Provider at all times. Y N
I agree that my child may visit a neighbour or friend’s home without the physical presence of the Provider, BUT MUST BE VISIBLE to the Provider at all times. Name of neighbour/friend:_________________________________ Phone #: ___________________________
Y N
I agree that my child may take a taxi to/and from the Provider’s home. Y NI agree that my child may walk to take the school bus without the physical presence of the Provider, BUT MUST BE VISIBLE to the Provider at all times. Y N
I agree that my child may walk to take the school bus without the physical presence of the Provider if he/she is accompanied by an older child.Name of older child:______________________________________ Age:_______________
Y N
MEDICAL INFORMATION
Child’s Name:_________________________________
Child’s Health Card Number and Version Code:__________ - _______ - _______ - V_______ Allergies: ______________________________Reaction:____________________________________________________ Family Physician or (Clinic frequented)___________________________________________________________________ Address:____________________________________________ Phone Number:_______________________________ Does your child;
Take prescribed medication on a continual basis Y / NDetails:
Have history of communicable diseases Y/N Specify:
Have any past medical history of Y / NChicken pox measles small pox mumps scarlet feverOther;
Have any past injuries or surgeries Y / N Specify:
Require corrective devises Y / N Shoes, prostheses, glasses, hearing aids other;Specify:
Have issues with vision, hearing, speech, dental Y / N specify:
Have any birthmarks Y / N Specify:
Have any fears or phobias Y / N Specify:
Frequently suffer from the following Y / NColds Flu Croup Earaches Stomach aches Fevers Constipation Tonsillitis Other;
Was this child ever referred to an agency Y / NSuch as; Infant Development, Children’s Treatment Centre, Child Care Resources, Children’s Community Network, Word Play, Other
Please list any other medical information concerning your child you feel the Home Provider should be aware of and/or may affect his/her Child Care experience and/or progress__________________________________________________________________________________________________
__________________________________________________________________________________________________
ImmunizationA photocopy of your child’s Immunization Record is required prior to enrolment.
The Ministry of Health Program Standards, states that all children registered in Licensed Child Care Programs, must be immunized against; Diptheria, Pertussis, Tetnus, Polio, Measels, Mumps, Rubella and Haemophilus, Influenza Type B, unless exempted by the Medical Officer of Health. ____________________________________________________________________________________________________________
Please complete the following Immunization History form and attach photocopy of Immunization Record.
Please attach a photocopy of your child’s immunization record.
Jubilee will forward immunization information to the Sudbury & District Health Unit. For more information please contact the Sudbury & District Health Unit at 705.522.9200
or visit their website at http://www.sdhu.com
NUTRITIONAL INSTRUCTION
It is the policy of InHome Child Care to provide your child with nutrition according the CCEYA- Home Day Care Regulations and the Canada food Guide as well as per parental instruction. InHome Child Care believes that it is also important to guide children in making “good choices” regarding their nutrition.
The following information, collected on each child, helps the provider to safely and constructively plan his / her menus for individual children as well as the group.
Child is allergic to: __________________________________________________________________________________
Child is not to have the following food and/or drink: _________________________________________________________________________________________________________________________________________________________
Other particulars concerning child’s nutritional requirements and or preferences:__________________________________________________________________________________________________________________________________ Do you have any concerns regarding your child’s eating habits: _________________________________________________________________________________________________________________________________________________
Food my child prefers: _________________________________________________________________________________________________________________________________________________________________________________
Food my child will not eat: ______________________________________________________________________________________________________________________________________________________________________________
INFANT AND TODDLER
Parents are to supply nutrition for children not yet on the Providers menu.All food must come in the original containers, when possible and labelled with the child’s name and date.
It is strongly recommended that infants be introduced to only one new food per-week. Therefore, it is of great importance that parent and provider discuss the infant’s eating habits frequently, noting new foods introduced and any reaction to food that may have occurred.
Are you breastfeeding your child? Yes / No If yes, does your child also feed from a bottle? Yes / No
Does your child receive a bottle? Yes / No If yes, at what time(s) / / / /
Do you have any objections to an extra feeding if demanded by your child? Yes / No
Does your child receive baby food/solids? Yes / No _______________________________________________________
Does your child feed themselves yet? Yes / No ___________________________________________________________
If in transition of feeding themselves, what foods are manageable for them at this time? ____________________________________________________________________________________________________________________________
INFANT FEEDING INSTRUCTIONS
According to the CCEYA- (Child Care and Early Years Act) Infants under one year of age must be accompanied with written feeding instructions from a parent/guardian.
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Parent/Guardian___________________________________ Date________________________________
INFANT CARE
What is the best way to comfort your child?______________________________________________________________
Soother: Does your child sleep with it? Yes / No ___________________________________________________________
Walk around with it? Yes / No _________________________________________________________________
How often do you burp him/her during their bottle? _______________________________________________________
Do they have a strong attachment to a security item? ______________________________________________________
How do you put them to sleep? ________________________________________________________________________
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Does this child like to be rocked? Have their back rubbed? __________________________________________________
Does this child like to sleep on their backs or their side? ____________________________________________________
Does this child sleep in a crib? _________________________________________________________________________
Does this child sleep with you? _________________________________________________________________________
What times does this child usually go for a nap? ___________________________________________________________
How long does this child usually sleep? __________________________________________________________________
Is this child trying to walk? ____________________________________________________________________________
Does this child hold on to furniture? ____________________________________________________________________
Physical Development to date (rolling over, sitting up by self, crawling, walking around furniture, etc)
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SCHOOL AGE CHILDREN
Your child is enrolled in the school age program which is available for before and after school care. We also have an all day program which is available on Professional Development days and on school holidays (March Break and Summer) in addition to Statutory holidays.
If you would like care for your child in a full day program, you must request in advance with the provider.
The following information, collected on each child, helps the provider plan programming for individual children’s interests as well as the groups
Does your child have any difficulties in speaking or comprehending? __________________________________________
How does your child feel about school? _________________________________________________________________
Previous school concerns? ____________________________________________________________________________
Current involvement in extra–curricular activities; Brownies, Scouts, swimming, hockey etc..._______________________
__________________________________________________________________________________________________
What are your child’s favourite activities / interests?_______________________________________________________
Does your child enjoy/prefer playing alone?______________________________________________________________
What makes your child angry or upset and how does he/she show these feelings?_______________________________
__________________________________________________________________________________________________
How would you suggest the provider handle your child when angry or upset?___________________________________
__________________________________________________________________________________________________
Does your child have any fears?________________________________________________________________________
Are there particular ways you think we might be able to help your child?_______________________________________
__________________________________________________________________________________________________
Name some interests and activities that have particular meaning to your child (such as reading, skipping, etc...)________
__________________________________________________________________________________________________
What special days do you celebrate (such as religious holidays, birthdays etc...) How do you celebrate them?__________
__________________________________________________________________________________________________
What kinds of activities or events does your family participate in the community (such as going to the park, Dragon boat
Festival, etc...) _____________________________________________________________________________________
__________________________________________________________________________________________________
What type of activities would you like to participate in at our agency (such as cooking activities, becoming a board
member etc...)______________________________________________________________________________________
CHILD ATTENDING SCHOOLYour Provider needs to be aware of child’s school and transportation in case of an emergency.
This information is needed to be accurate and up-dated at all times.
This information may be used in locating a child who has either missed their bus, fallen asleep on the bus and do not
get off at their scheduled stop, or for any other emergency situation where the bus lines or school needs to be
contacted.
School:___________________________________________ Phone:___________________________
Address:__________________________________________ Teacher:_________________________
Grade:______ Duration of School: Days: ______ to _______ Hours: _____to_____ BUS
Bus Line: ____________________________________________ Phone: __________________________
Location child gets on the bus to school: ______________________________________________ Time:_____________
Route: _______________ Driver Name: _________________________________
Location child gets off the bus from school: ____________________________________________ Time:_____________
Route: _______________ Driver Name: _________________________________
Should there be a day your child will not be arriving via school bus, the parent must ensure the provider is notified.
In the event your child does not get off the bus as scheduled, the Provider will immediately take action in locating
your child.
Phone calls will be made to emergency contacts as listed in the child’s file, Jubilee, the school bus lines, and anyone
else necessary.
PAYMENT AGREEMENT
Billing by JHFR InHome Program, is determined by the most recent Enrolment Agreement and Fee Schedule. (as listed below);
It is the client’s responsibility to keep their enrolment agreement up-to-date.
Two weeks notice is required, in writing, for any changes to your enrolment agreement, including vacation time and termination of this agreement. In the case your Provider cannot accommodate the new enrolment we will try our best to find an alternate spot for you.
PROGRAM DURATION 0-18 Months 18-30 Months 30 Months-SAC Part Day up to 6 hours $29.00 $26.00 $25.50Full Day 6 hours + up to 9 hours $41.00 $37.00 $35.00Extended Day 9 hours + up to 12 hours $48.00 $39.50 $39.00Extended Day + 12 hours + up to 16 hours $56.50 $50.50 $50.00Extended Day ++ 16 hours + up to 20 hours $71.50 $64.50 $64.50Maximum Day 20 hours + up to 24 hours $87.00 $72.50 $71.50Before School up to 2 hours $10.00After School up to 2 hours $13.00Before & After up to 4 hours $16.50SAC up to 6hrs Up to 6hrs $24.00SAC up to 9hrs Up to 9hrs $30.00SAC up to 12hrs Up to 12hrs $38.00SAC up to 16hrs Up to 16hrs $49.00SAC up to 20hrs Up to 20hrs $63.50SAC up to 24hrs Up to 24hrs $66.50
Attendance Registers are submitted to JHFR office on the 15th and the last day of each month, by the provider. Your initial is required on the attendance register each day of your child’s scheduled attendance, as well as your signature at the end of the period.
Do NOT SIGN the attendance in advance or all at once at the end of the month.
You are accountable for what you sign since your signature verifies what you will be invoiced for.
Please do not forget to sign as your Provider cannot send in the register until ALL initials and signatures are entered.
Any adjustments to your bill will be done after that information is received at the JHFR office.
Invoices are sent out on the 10th day of each month. Payment will be due before the 15th of that month.
Payment methods accepted by JHFR-InHome Program include; cash, cheque, online payments, or money order.
Subsidize Spots: A subsidized client may not receive an invoice unless they have used care above and beyond what their subsidy agreement allows. The parent is responsible for payment of such fees.
It is the subsidy clients responsibility to keep their file with the City up to date to ensure coverage of daycare fees.
Other Charges that may apply include; Late payment fee of 2% is charged to account balances on the 20 th of each month and returned payment fee of $20.00 (NSF charge)
Accounts delinquent after 30 days may be collected through another agency and may jeopardize your child’s daycare spot.
Tax Receipts for Child Care paid within the previous year, will be issued by the end February.
Dear Parents/Guardians:
The City of Greater Sudbury may provide you and your family with subsidized childcare through our Agency. If you require further
information, please call 311 and ask to speak to Children’s Services. You will be transferred to a representative and will qualify you
over the phone based on information you provide. Once the City has determined if you would qualify for subsidized childcare, they
will schedule an appointment with you. Please note that subsidy isn’t automatically approved and the process can take up to a
month based on your family composition etc.
Jubilee will receive confirmation from Children’s Services once your subsidy is approved. Should you wish to start your child in care
prior to subsidy approval we request a continuous 2 week pre payment of childcare until we have received your subsidy approval.
Jubilee will refund any monies according to the subsidy agreement and start date.
ENROLMENT AGREEMENT
Child’s Name: ________________________________________ Start Date: ___________________
Date of Birth: ____________ /___________ /___________ Discharge Date: ________________
Number of days contracted for/per month:_____________
Code:___________________ / ______________________ Code:___________________ / ______________________
THE FOLLOWEING SCHEDULE IS: ON-GOIGN; _____ OR, FOR THE TIME PERIOD; __________to__________
Please note: When establishing your child’s attendance schedule, please ensure that you have sufficient travel time to allow for the “arrival” and “departure” times you commit to.
1st
WK Arrival / Departure 2ND
WK Arrival / Departure 3RD
WK Arrival / Departure 4TH
WK Arrival / Departure
MON___
_______ / ______________ / _______
MON___
_______ / ______________ / _______
MON___
_______ / ______________ / _______
MON___
_______ / ______________ / _______
TUE___
_______ / ______________ / _______
TUE___
_______ / ______________ / _______
TUE___
_______ / ______________ / _______
TUE___
_______ / ______________ / _______
WED___
_______ / ______________ / _______
WED___
_______ / ______________ / _______
WED___
_______ / ______________ / _______
WED___
_______ / ______________ / _______
THU___
_______ / ______________ / _______
THU___
_______ / ______________ / _______
THU___
_______ / ______________ / _______
THU___
_______ / ______________ / _______
FRI___
_______ / ______________ / _______
FRI___
_______ / ______________ / _______
FRI___
_______ / ______________ / _______
FRI___
_______ / ______________ / _______
SAT___
_______ / ______________ / _______
SAT___
_______ / ______________ / _______
SAT___
_______ / ______________ / _______
SAT___
_______ / ______________ / _______
SUN___
_______ / ______________ / _______
SUN___
_______ / ______________ / _______
SUN___
_______ / ______________ / _______
SUN___
_______ / ______________ / _______
I herby agree that the above listed schedule contains accurate times of arrival and departure of my child(ren.)
If I arrive earlier or later than the above times, I may be charged an early and/or late fee according to my Providers policy.
I agree to give my provider and the agency 2 weeks written notice, of ANY change in the above schedule, including vacation time and termination of care.
Your provider may not always be able to accommodate a schedule change; however, JHFR-InHome Program will do our best to meet your scheduling needs.
I agree that JHFR-InHome Program has reserved the above schedule for my child and I will be invoiced accordingly, including any absent days for any reason, including up to 3 Professional Development Days in which JHFR-InHome Program is closed
_______________________ ______________________
PARENT SIGNATURE DATE
PARENT/CLIENT CONTRACT
1. _____The parent/client will comply with the agreed upon days and hours of child care, based on the enrolment schedule.
2. _____The parent/client will ensure that the child arrives and is picked up at the provider’s home at the agreed upon time.The parent/client understands that he/she may be charged an additional fee directly by the provider for early drop-off or late pick-up, pursuant to the provider’s policies.Jubilee Heritage Family Resources-InHome Child Care does not negotiate process or administer late fees or any other penalties; these are strictly a matter between the parent and the provider to determine.The agency will become involved in a matter where early drop-offs or late pick-ups interfere with licensed capacity regulations.
3. _____The parent/client agrees to inform the provider the night before, if possible, when the child will not be present the following day. Otherwise, the parent/client agrees to inform the provider at least one hour prior to the child normal arrival time.
4. _____The parent/client agrees to give the Provider and JHFR InHome Program office a minimum of two weeks written notice of any changes to the enrolment schedule.The parent/client agrees to ensure a new enrolment agreement schedule is signed by the parent when changes to the agreement occur.If a provider cannot or is not willing to accept the change in schedule, the parent must notify the office so another placement can be arranged, if possible.
5. _____The parent/client agrees to give the Provider and JHFR office a minimum two weeks written notice of termination of care. In the case of immediate discharge, the parent understands that full program fees will be invoiced for the duration of the two weeks.
6. _____The parent/client agrees to initial the attendance form daily, upon drop off and pick-up, to verify hours of care in attendance.The parent/client agrees to sign the attendance record at the end of the month to verify monthly attendance and to verify any changes required. Families or provider may record the hours of pick and drop off on the attendance register.
7. _____The parent/client understands and agrees to follow JHFR-InHome Program Payment Agreement
8. _____The parent/client will ensure that all information in the child’s file is kept up-to-date.The parent/client will inform the Provider and JHFR-InHome office, in writing, of any changes.(i.e. immunization, contact information, marital status, child’s health, ect.)
9. _____The parent/client agrees to advise the Provider and JHFR-InHome Program office of any allergies, special dietary concerns or eating problems of the child.In the case of a special diet, it will be necessary for the parent/client to supply the food.
10. _____The parent/client agrees to advise the Provider and JHFR-InHome Program office when unavailable in the case of an emergency, and agrees to provide the name and phone number of an alternative person that will be available to pick up the child if necessary.
11. _____The parent/client agrees to supply baby food and formula along with parental written feeding instruction for infant.The parent/client understands that when the child begins eating table food, the provider will supply the food unless the parent/client requests substantially different food normally served by the Provider.This transition will be discussed with the provider.
12. _____The parent/client agrees to ensure the Provider has an adequate supply of diapers, wipes and creams if the child is not toilet trained. Required personal items for a child may vary, depending on the provider’s policies.
13. _____The parent/client will ensure the provider has a clean change of indoor clothing and appropriate outdoor clothing for the child at all times. Required personal items for a child may vary, depending on the provider’s policies.The parent/client understands that the Provider and JHFR-InHome Program are not responsible for lost, stolen or damaged items.
14. _____The Parent/client agrees that the child is not to attend day care if he/she has a communicable disease, an infection or serious illness. The parent/client will inform the Provider and JHFR-InHome Program office if the child has any of the above conditions and it
may be necessary for the parent/client to present a Dr’s note to the Provider, stating that the child is able to return to the day care.
15. _____The Parent/client agrees the provider can only administer recently prescribed medication in the original container, as supplied by the pharmacist. Non- prescription medication, such as Tylenol can only be administered if accompanied by a Dr’s Note.
16. _____The parent/client understands that it is the Provider’s and JHFR-InHome Program Staff’s PROFESSIONAL OBLIGATION TO CONTACT The Children’s Aid Society in cases where:
there is suspicion of child abuse; orThe child has not been picked up after one hour past closing time and listed contacts cannot be reached
17. _____The parent/ client agree to discuss progress and/or concerns regarding the child and care arrangements with the Provider. (i.e. daily activities)The parent/client is encouraged to communicate openly with the Provider and the agency to alleviate any concerns regarding the care their child is receiving.
18. _____The parent/client understands that the provider or JHFR-InHome Program will attempt to make alternate arrangements for the child’s care in the case of provider illness, vacation, or termination for the agency, upon request with reasonable notice, where possible.
19. _____The parent/client agrees to keep positive communication open with their provider and the agency.I understand that if I have any concern I cannot work out with the provider, I am welcome to call the agency for assistance. I am aware that agency contact information is listed below and at my Providers.I am also aware that the Agency cell number given is for emergency purposes only.
20. _____The parent/client agrees that the child may be discharged if;
The child does not attend the day care according to the enrolment schedule A disruption of attendance has a negative impact on the child or program The needs of the child cannot be met by the program as determined by the administrator.
21. _____The parent/client understands that failure to comply with this agreement will result in the child being discharged from the Jubilee Heritage Family Resources-InHome Child Care Program.
22. _____The parent/client understands that this agreement supersedes any previous agreement, and is effective until further notice.
23. _____The parent/client acknowledges that the Provider is a self-employed, independent contractor and is not an employee of Jubilee Heritage Family Resources-InHome Child Care, or any other program.
*Please note: reference to “the parent/client” is in reference to the “legal guardian” of the child*
I, the undersigned, hereby certify that I have read, understand and will abide with the above mentioned conditions and the policies and procedures as outlined in the Jubilee Heritage Family Resources-InHome Child Care Client Handbook.
Parent/Client signature: ______________________________________________ Date: ____________________________________
ONTARIO CHILD AND FAMILY SERVICES ACT (CFSA)
The Ontario Child and Family Services Act recognize that each person has a responsibility for the welfare of children. It states clearly that members of the public, including professions who work with children have an obligation to report promptly, to a children’s Aid Society (CAS); if they suspect that a child is or may be in need of protection. CFSA s.72(1) A child in need of protection is a child that has experienced physical, sexual and emotional abuse, neglect and risk of harm.
As professionals in the field of Early Childhood Education, we are obligated to contact the CAS if we have reason to believe that:
The child has suffered physical harm, inflicted by the person having charge of the child or caused by or resulting from that person’s
a) Failure to adequately care for, provide for, supervise or protect the child or b) Pattern of neglect in caring for providing for supervising or protecting the child
There is a risk that the child is likely to suffer physical harm inflicted by the person having charge of the child or caused by or resulting from that person’s
a) Failure to adequately care for, provide for, supervise or protect the child or b) Pattern of neglect in caring for providing for supervising or protecting the child
The child has been sexually molested or sexually exploited, by the person having charge of the child or by another person where the person having change of the child knows or should know of the possibility of sexual molestation or sexual exploitation and fails to protect the child.
There is a risk that the child is likely to be sexually molested or sexually exploited as described in paragraph 3. The child requires medical treatment to cure, prevent or alleviated physical harm or suffering and the child’s
parent of the person having charge of the child does not provide, or refuses or is unavailable or unable to consent to, the treatment.
The child has suffered emotional harm of the kind described in sub paragraph l, ii, iii, iv, v of paragraph 6 and the child’s parent or unable to consent to, services of treatment to remedy or alleviate the harm.
Professionals who work with children have a responsibility to report their suspicions, therefore failure to report is an offense in accordance to CFSA s.72 (4), (6.2)
Any professional who fails to report a suspicion that a child is or may be in need of protection duties, is liable on conviction to a fine of up to $1000. The Professional’s duty to report overrides the provisions of any other provincial statute, specifically, those provision that would otherwise prohibit disclosure by the professional. CFSAs 72 (7), (8).
If you have any questions or concerns about the Child and Family Services Act s.72 (1) please feel free to speak to the Daycare Supervisor, or contact your local Children’s Aid Society.
Thank you for your understanding of our professional obligation.
Please sign below indicating you have read and understand the above Child and Family Services Act.
__________________________________ ______________________________________ Parent(s) / guardian(s) Signature Date
Welcome to Jubilee Heritage Family Resources and our InHome Program. We are pleased to be able to provide you and your family with quality childcare.
While in our InHome Child Care Program you will be expected to:
Complete the Intake package
Complete and adhere to your enrolment agreement. If at any time you need to change, alter or temporary
suspend your enrolment agreement, 2 weeks notice must be given to your provider and Jubilee InHome Office.
If you should not adhere to your enrolment agreement after 3 consecutive days, you will be asked to change the
enrolment agreement between you and your provider. If the provider cannot accommodate such changes, you
will be placed with a new provider at your request.
If at any point you do not use the care that you have requested, you will be financially responsible for paying the
difference in which the 3rd party doesn’t pay. For instance, you have requested extended days, but use only a full
day you will be financially responsible for the difference in price between the 2 care codes.
If a 3rd party is responsible for paying your attendance, it is mandatory that you adhere to their guidelines to
ensure payment for your child’s attendance.
If at any point in time, you do not adhere to the 3rd parties’ request, you will be expected to pay for the
attendance in which the 3rd party did not cover.
If your child is sick for more than 2 days within 1 month, a Physician’s note may be requested by the 3rd party to
ensure payment of attendance.
If you plan to take a vacation or an extended leave, it must be approved by the 3 rd party and Jubilee. If you don’t
adhere to this request, you may be financially responsible for absent days, and in which case you will be asked to
pay in advance to taking the leave.
Monthly contributions must be received by the 20th of each month. If monies are not received, 3rd party will be
notified, and you will be asked to leave the program, and be financially responsible for the attendance that was
not covered by the 3rd party.
IF the 3rd party has requested a work schedule, it is expected that the schedule be provided no later than the 1 st
day of the following month. For instance July’s work schedule is expected on August 1st. If a work schedule isn’t
provided, you will be asked to leave the program, and you will be financially responsible for the attendance taken
within that time period.
Please adhere to your work schedule, please note that 30 minutes will be allotted for travel to and from your
place of employment after leaving your child in the InHome Program as per Childcare Services policies.
Providers have requested that you provide them with your work schedule at least 2 weeks prior to the
attendance being taken.
Childcare fees must be paid within 2 weeks of receipt of the invoice.
It is expected that you communicate with your provider, the 3rd party and Jubilee if you are unsure, or have any
questions regarding your child’s attendance and/or billing.
I have read and understand the above mentioned policies
Parent/Client signature: ______________________________________________ Date: ____________________________________
Thank you, we look forward to having you apart of our jubilee Family. If you have any question, please feel free to
contact us, our door is always open and the coffee is always on.
Sincerely,
Karrie YakeOffice CoordinatorJubilee Heritage Family Resources 189 Applegrove St. Sudbury, ON. P3N 1N4 PH- 705.674.3334 x [email protected]
General Consent FormFreedom of Information and Privacy Act
The information contained in the attached form(s) and in other documents and materials used to support the InHome Childcare Program is collected for the operation of the InHome Program. InHome Childcare has the authority to collect this information under the CCEYA. Questions about this collection can be directed to; Director, InHome Child Care, 189 Applegrove Street, Sudbury, ON. P3C 1H4., telephone (705)674.6552 x 232
Parent Initials:___________________________
Medical Authorization and Release
The undersigned, who are legal parents or guardian(s) of the child stated below, herby authorize the Provider, associated with InHome Childcare agency, into whose care the below named minor has been entrusted, to consent to any X-ray, examination anaesthetic, medical or surgical diagnosis or treatments, and hospital care to be rendered to said minor under the general or special supervision and upon the advice of a physician and/or surgeon, or to consent to an X-ray, examination, anaesthetic, dental or surgical diagnosis or treatment, and hospital and hospital care to be rendered to said minor by dentist.The undersigned further authorize the Provider, associated with above named agency, to have the below named minor released into the custody of its representative, should hospital care no longer be required.This authorization is to be used only in an extreme emergency, when said parents/guardians cannot be or are or are unavailable to be contacted in sufficient enough time.
Parent Initials:___________________________
Travel and Outings
Jubilee InHome Childcare daily programs usually include field trips outside of the provider location. (ie. daily walks to the park, etc.) Signing below indicates that you are willing to have your child taken from the routine trips by Foot Only.Our understanding is that:-Your Provider will make you aware of their daily routine of “off Premise: locations that are frequented- Normal safety precautions are taken at all times- You will be informed by your provider of any special outings other than the above mentioned routine outings and will be asked for permission for such- Neither Jubilee nor the provider shall incur any responsibility or liability for any loss or damage to property sustained while participating in outings
Parent Initials:___________________________
Photography Information
Signing below indicates that you authorize for the child stated below, to be photographed or video recorded while enrolled with the InHome Childcare program. None of these photos or videos will be used for profit making ventures; however, they may be used as promotional material for the agency. Such photos are used for the parents benefit of being aware of their child’s experience.
Parent Initials:___________________________
Sunscreen Use
Signing below authorizes your childcare Provider to apply sunscreen to your child as required. The Provider will either require you to bring your child’s own brand of sunscreen or will make you aware of the brand he/she uses.
Parent Initials:___________________________
PLEASE NOTE THE ABOVE “X” INDICATED ALONGSIDE THE PARENT INITIAL, INDICATING THAT AUTHORIZATION IS NOT GIVEN FOR THIS PATICULAR POLICY.
For Child:_____________________________________________ D.O.B:________________________________ Parent Signature:_______________________________________ Date:________________________________
Transportation Agreement
PLEASE NOTE THE ABOVE “X” INDICATED ALONGSIDE THE PARENT INITIAL, INDICATING THAT AUTHORIZATION IS NOT GIVEN FOR THIS PATICULAR POLICY.
For Child:_____________________________________________ D.O.B:________________________________Parent Signature:_______________________________________ Date:________________________________
Parent/Guardian Responsibilities
The Ontario Government’s new legislation effective September 1st 2005 states that drivers are responsible for ensuring passengers under 16 years of age are secured properly.It is mandatory for anyone transporting children to make sure they are properly secured in a child car seat or booster seat. The provisions are applicable to any driver who transports children in a vehicle, including parents, babysitters, legal guardians, caregivers, day nursery and private home daycare providers and agency staff. Failing to do so may result in a $110.00 fine plus 2 demerit points. Persons exempt from these provisions are bus drivers and taxi drivers or a public vehicle, while transporting passengers for hire, and persons who are unable to wear a seatbelt assembly due to certified medical condition or physical characteristic.
I, the undersigned adult, responsible for the transportation of my child to and from the Childcare Program, have read, understand, and agree to abide by the information paper titled “ Safe and Secure”, which contains particulars on the Ontario Government’s new legislation listed under Motor Vehicle Safety Act, on transporting children.I will ensure that anyone else I put my trust in to provide transportation for my child, is aware of this agreement and will abide by it accordingly.
Provider Responsibilities
InHome Childcare daily programs usually include field trips outside of the providers location. Any trips outside of the premises that require transportation by vehicle will be required to follow the Motor Vehicle Safety Act, regarding the transportation of children.Providers who plan to use their vehicle are required by InHome childcare agency to obtain a certificate from the Sudbury and District Health Units Car Seat Clinic, stating they have attended the training session and that all Vehicle Child Restraint System they are using has been inspected for proper installation and use, prior to transporting children.
The agency’s understanding is that the provider will;-Make sure clients are aware of any “off premise” trips that require transportation of their child.- Will ensure that they have clients written permission before transporting the child in a vehicle.- will ensure that normal safety precautions are taken at all times.
We, as signed below, have read the above and agree to abide by the requirements as stated.We understand that failure to abide by the above stated requirements could result in a report to the appropriate authorities for failure to provide protection for the child.
For more information on child booster seats and child restraints contact: The Ministry of Transportation INFO general inquiring toll free at 1.800.268.4686And/or website at: http:// www.mto.gov.on.ca/english/faq/safety.htm#passenger.
Child’s Name:____________________________________________________
Allergies or Medical Conditions:_____________________________________
Parents Name:___________________________________________________
Parent Telephone Number while child is in care:__________________________
Parent Address while child is in care:____________________________________
Dr. Name:________________________________________________________
Dr. Address:_______________________________________________________
Dr. Telephone Number:______________________________________________
Emergency Contact: ______________________Tel:________________________
Emergency Contact: ______________________Tel:________________________
