ID # _______________

Little Rascals Child Care Learning CenterALLERGIES

Child’s Name: _____________________________

Allergy: Yes No

Allergy to:

Food: __________________________________

Medication: ______________________________

Other: __________________________________

Parent/Guardian Name _____________________________________________

Parent/Guardian Signature __________________________ Date: ___________

187 Miller Place Yaphank RoadMiller Place, New York 11764

631 474-7080

Emergency Form

We/I_______________________________ give our permission to (Parent’s name)Little Rascals Child Care Learning Center to obtain emergency

health care and emergency transportation for our

son/daughter______________________in the event of accident or (Childs’s name)illness.

I do not give my permission

______________________________________________________ (Parents signature) (date)

ID # ______________

Little Rascals Child Care Learning Center

CHILD ILLNESS POLICY

o If your child has a fever over 100 degrees, is vomiting, has 2 loose bowel movements or has any unexplainable skin rash, he/she must be picked up from the center immediately and remain home for 24 hours before returning to Little Rascals.

o Please keep your child home if they have cold symptoms, which prevent participation in the program, if your child has a deep bronchial cough, and if your child is medicated to the extent that he/she falls asleep or is very irritable.

o If a doctor has put your child on antibiotics, he/she must have been taken them for 24 hours before he/she may return to the center.

o Your child must be free from communicable diseases listed on the attached schedule.

o As a licensed childcare provider, we are required to obtain a Physician’s note for certain types of injury or illness and all medications to be administered to your child. Parents will be notified in these cases.

o For your child’s safety, we require that parents notify the director in writing of any allergy or medical condition your child has or develops. This allows us to properly record and distribute the information to necessary staff.

These standards are to ensure the health and safety of All the children and staff within the center.

We appreciate your support.

I understand and agree to the above safety procedures for my child.

Parent/Guardian Name _____________________________________________

Parent/Guardian Signature ___________________________ Date: __________

ID # __________________

Little Rascals Child Care Learning CenterInfant Information Form

Child’s Name: _____________________________ Date: __________________

Schedule

Eating: Times: _________________________________________________

Amounts: _______________________________________________

Foods/Formula Given Warm or Cold: _________________________

Dietary Restrictions: ______________________________________

Sleeping: Times: _________________________________________________

Routine: (Blanket, rocked, pacifier) ___________________________

Position Preference (back or side) _________________________

Elimination: Recommended Times to Change: __________________________

Powder/Cream/Ointment: __________________________________

Times to use: ____________________________________________

Recent changes in family routine or environment that may affect your child: ____

Indications of developmental, vision, hearing, or speech delays: _____________

Please specify: ____________________________________________________

Language other than English spoken at home: ___________________________

Medications: ______________________________________________________

Comments: _______________________________________________________

We/I ___________________________________ give our permission to Little Rascals

Child Care Learning Center to let our son/daughter_______________________________

sleep on a mat during Nap time. We understand that our child will be napping on a mat

in their classroom during napping hours.

We/I do not give permission for our child to sleep on mat.

We/I give permission for our child to sleep on a mat.

Parents Signature__________________________________

Date_______________________

ID # _______________

Little Rascals Child Care Learning CenterParent Authorization Form

Child’s Name: ___________________________ Date of birth: ______________

Parent/Guardian Name: ___________________ Today’s Date: ______________

Little Rascal’s staff may use the following products, which I have provided and which are clearly labeled, on my child:

Please place a check next to each Item (authorized or not authorized)

Product Authorized Not Authorized

Diaper Ointment

Diaper Wipes

Diaper Powder (Talc Free)

Baby Lotion

Sunblock

Chapstick

I understand that photographs of my child will be used for school events only. Photographs for any other purposes willnot be used unless permission is granted.

Parent/Guardian Name ____________________________________________

___________________________________ _____________________ Parent/Guardian Signature Date

Little Rascals Child CareLearning Center

Parent Handbook Receipt

This acknowledges that you are in receipt of Little Rascals Child Care Learning Center’s Parent Handbook which includes: our school philosophy, program information, schedule of your child’s day and our centers illness policy. If you have any questions on any information that was proved to you feel free to speak to our director or owner.

Child’s Name___________________________________________________

Parent/Guardian Name:__________________________________

Parent/Guardian Signature: _______________________________ Date:__________________

ID # ____________

Little Rascals Child Care Learning CenterPersonal Childhood History

Child’s Name: ______________________________Date of Birth: ___________

Sleeping Habits______________________________________________________________________________________________________________________________________________________________________________________________________________Eating Habits________________________________________________________________________________________________________________________________________________________________________________________________________________Toilet Habits________________________________________________________________________________________________________________________________________________________________________________________________________________Siblings Names and Ages__________________________________________________________________________________________________________________________________________________________________________________________________________________Child Disposition___________________________________________________________________________________________________________________________________________________________________________________________________________ Additional Comments____________________________________________________________________________________________________________________________________________________________________________________________________________

ID # ____________

Little Rascals Child Care Learning CenterPersonal Childhood History

Name: __________________________________________________________

Date of Birth: ___________

Members Of The Household (Including Parents)

Name Age Relationship

Personal History

Parent(s) that live in the household: ___________________________________

Pets:

Names: _____________ ____________ _____________ _______________

Type: _____________ ____________ _____________ _______________

Has your child had any other group or school experiences? ________________

Child’s Special Interests: ____________________________________________

Does your child speak in sentences? ____Does your child speak in words? ____

Does your child have a difficulty in speaking? ___________________________

Any special services? ______________________________________________

Any other languages spoken at home? _________________________________

Special words to describe your child’s needs? ___________________________

How do you discipline your child? ________________________________________________________________

________________________________________________________________

________________________________________________________________

Health History

What arrangements can you make for care during illness? _________________

________________________________________________________________

Doctor’s Name: _______________________ Phone #: ____________________

Insurance Carrier: _____________________ ID #: _______________________

Please provide the center with a copy of your child’s Insurance card. Received_____

What communicable disease has your child had?

Please

Measles

Mumps

Chicken Pox

Whooping CoughOther

Describe: Other

Describe:

Has your child ever has any serious illness or hospitalization? _______________

________________________________________________________________

Preferred Hospital? ________________________________________________

Any Physical disabilities? ____________________________________________

How does your child react to elevated temperatures? ______________________

Any special instructions of your child becomes ill? ________________________

Are there any medications given regularly? ______________________________

Eating Habits

Is your child normally hungry at mealtimes? _____________________________

Is your child normally hungry between meals? ___________________________

What are your child’s favorite foods? ___________________________________

What foods are refused? ____________________________________________

What eating problems does your child have? ____________________________

Are there any special diet instructions? _________________________________

Does your child use eating utensils? __________________________________

Toilet Habits

Does your child indicate his/her own toileting needs? ______________________

What words are used for urination and bowel movements? _________________

Is your child afraid of the bathroom? ___________________________________

How much assistance does your child need with toileting? __________________

When was toilet training started? __________ When Accomplished? _________

Is your child in underwear? _________________ Pull-ups? _________________

Does your child wet the bed during naptime? _______ How often? ___________

Sleeping Habits

What time does your child go to bed? _____________ Awaken? _____________

Does your child walk, talk, or cry during sleep? ___________________________

What does your child usually take to bed? ______________________________

Does your child take naps? _____ From: __________ To: ___________

What is your child’s mood upon awakening? _____________________________

Social Relationships

Has your child had any experience in playing with other children? ____________

________________________________________________________________

By nature is your child…

Friendly

Aggressive

Shy

WithdrawnOther

Describe: Other

Describe:

How does your child get along with any brothers or sisters? _________________

Does your child like to be alone? ______________________________________

How does your child relate to strangers? ________________________________

Does your child demand a lot of attention? ______________________________

What causes your child to be angry or upset? ____________________________

How does your child show feelings? ___________________________________

What do you find is the best way to handle your child? _____________________

Is your child afraid of…

Animals

Rough Children

Darkness

StormsOther

Describe: Other

Describe:

What are your child’s favorite toys or activities at home? ___________________

Does your child like to be read to? _____________________________________

Does your child like to listen to music? _________________________________

Does your child prefer to play outdoors? ________________________________

Has your child had Experience with…

Clay

Scissors

The Easel

Blocks

Finger Paint

Water Play

Additional Notes or Comments

In what way can we help your child? ___________________________________

Briefly describe your child’s personality and abilities: ______________________

Thank you for sharing this helpful information with us so we can better understand the individuality of your child!

Parent/Guardian Name _____________________________________________

Parent/Guardian Signature: __________________________________________

Little Rascals Learning Center187 Miller Place Yaphank RoadMiller Place, New York 11764

631 474-7080 Phone631 474-7084 Fax

www.littlerascalsli.com

Shelter in Place

New York State now requires all daycare centers to practice Shelter in Place drills.

Shelter in Place is a response to an emergency that creates a situation in which it is safer to remain in the building rather than to evacuate. Generally, Shelter in Place means simply staying indoors. In some situations, sheltering in place includes additional precautions like locking all doors, closing all window shades, remaining in a room away from large windows or turning off heat and air conditioning systems. Some situations that might require sheltering in place are: severe weather, extreme temperatures, a public disturbance that escalated to violent acts, chemical or biological spill, etc.

In the event that our center has an emergency that requires us to shelter in place you will receive an email immediately, followed by a phone call explaining the situation at hand.

If the emergency requires the children to stay overnight, it is important to have supplies for each child. The state is requiring that each child have a supply of food/water in the event we should have to stay overnight. Please bring a zip lock bag, labeled with your child’s name, a non-perishable food item and bottle of water. If you have an infant, please provide extra formula/baby food in a zip lock bag clearly labeled with their first and last name.

We all hope to never experience an emergency, but it is better to be fully prepared and ready just in case of the event of having to shelter in place. Thank you for your cooperation.

Amanda Kolm- DirectorJacquelyn Amorello-Assistant Director

Little Rascals Learning Center187 Miller Place Yaphank Road

Miller Place, New York 11764631 474-7080 Phone631 474-7084 Fax

Tuition Payments Based On Contract

Please read Carefully

Please be aware that tuition is based on your contract not on attendance. If you are out sick or on vacation you still are

responsible for your tuition. Please understand our teachers are still paid and your child is taking up a spot in the class. If you

need to withdraw from a program please provide proper notification to avoid penalties.

Please be aware that exceptions will not be made to this policy.

Child’s Name___________________________________

Parent’s Name_____________________Date___________ Signed__________________________________________

187 Miller Place Yaphank RoadMiller Place, New York 11764

631 474-7080 Phone

631 474-7084 Fax

Please read carefully

I am aware that Little Rascals Child Care Learning Center requires no long-term commitment. In order to end a weekly program, I

only need to provide Two Week Written Notification to the Director. At this time your two-week deposit, which was left upon

registration, will be applied to the last two weeks your child attends the program. If your deposit does not cover the cost of the tuition, due to a change in schedule or tuition rate, you will then be

responsible for paying this difference upon this notification.

Please be aware that exceptions will not be made to this policy.

Child’s Name____________________________________

Parent’s Name________________________Date________ Signed__________________________________________