Child's name (Print)

PRESCHOOL

Registration Packet

Checklist

St. Joachim Preschool 310 North "I" Street Madera, CA 93637 Tel. (559) 674-7628

school@sjoachim.org

Parent/Guardian's name (Print)

Class Choice: (Please circle appropriate hours and indicate the week days of attendance)

4-5 days AM PM All Day 3 days AM PM All Day 2 days AM PM All Day

Please make sure that the following forms have been completed and submitted.

Forms: LIC 613A LIC 627 LIC 700 LIC 701 LIC 702 LIC 995

PS_Reg_Checkl ist_2019

LIC 995E (Signed copy) Immunization Record (copy) Admission Agreement (signed copy) Photo Release Handbook &Agreement

Tuition &Fees: Registration Fees Current Fees/balance Credit Balance Balance of Fees

Amount Owed: $ Amount Owed: $ Amount Due: $

St. Joachim Preschool Supply List

One backpack with your child's name Two bottles of Apple Juice 6aoz

Three containers of disinfectant wipes One container baby wipes

One box Kleenez 8 Glue Sticks

Do not mark names on the items. They go into a pool jor each class and we use all

the supplies. Thu helps to keep our costs down and is greatly appreciated.

Uniform Requirements (as per Preschool Handbook) Any clean, white shirts, navy blue pull on shorts, pants, sweatpants, socks and athletic shoes. Provide simple, sturdy clothing that is Free of complicated fastenings. Your child will be encouraged to use the restroom by himself/herself (under watchful supervision)

Provide your child with warm clothes on cold days and appropriate clothing to protect from the sun in hot weather. Shoes are required at all times and should fit well and be comfortable. Open toed shoes are discouraged for safety reasons. Please mark your child's clothing with a permanent marker. The backpack should be marked with the

child's name as well.

Important reminder: Please send a backpack with a complete change of clothes. This includes, top, bottom, underwear and socks. The changes of clothes

should be a uniform. We need an extra set of clothes in the event of a

juice spill, potty accident, and paint spills etc., Thank you.

PRESCHOOL PARENT/STUDENT

HANDBOOK AGREEMENT

Attendance at St. Joachim Preschool is considered an agreement on the part of the student and his or her parents/guardians to fully comply with all policies, rules and regulations of the school as outlined in the Parent/Student Handbook and as revised during the school year.

We, the parents(guardians) of:

(Student(s)' name)

Understand the above statement, and have reviewed the current handbook. We agree to comply with all the policies, rules, and regulations of the school.

*Please sign and return this agreement to the school, as it will become a part of the student's file and is

conditional to your contracted attendance at St. Joachim Preschool. This must be returned prior to your

child's attendance at our facility.

Parent /Guardian Signature Parent /Guardian (Printed Name)

Date

St. Joachim Preschool 310 North "I" Street Madera, CA 93637 Tel. (559) 674-7628

school@sjoachim.org

PS_Hndbk_Agree_2019

ST. JOACHIM

i G @ ~~~OUC~Q

HANDBOOK

2019-2020

310 North "I" Street, Madera, CA 93637

Phone: (559) 662-0372

POLICIES

ADMISSION

The school serves children who are 3 to 6 years of age. Children must be potty train. Any

child that continuously has accidents will be asked to wait a few months and then start

again. In order, for child should be considered for admission an application for

enrollment must be completed, followed by an interview with the preschool director to

determine appropriate class assignment.

Upon acceptance you must complete the registration packet containing the following

necessary forms: emergency authorization form, child's health history, physicians form,

immunization records, TB testing results, consent for emergency treatment, pazent's

rights form, personal rights form, child abuse form, admission agreement form, picture

release form and handbook receipt acknowledgment form.

PRIORITY ADMISSIONS POLICY

In the event that a waiting list is necessary to attend preschool, the priorities for

admission will be as follows:

Families with older siblings enrolled in Saint Joachim school or preschool.

Catholic families from Saint Joachim parish

- Catholic families from another pazish

- Non-Catholic

PAYMENTS OF FEES

There is a $95.00 non-refundable registration fee per child payable at the time of

registration. This fee includes the cost of insurance.

TUITION

The monthly tuition amount is listed in the table on your admission agreements of 15%

discount or additional children in the same family (either attending Saint Joachim

Preschool or Saint Joachim School) will apply. Tuition is to be payed monthly through

the FACTS online tuition collection service (more information to come). A monthly

$35.00 late fee will be assessed if not received by the 10~h and if there is no communication

to the principal.

2

CALENDAR YEAR

Preschool follows the Saint Joachim school calendar regarding holidays and scheduled

days off. The teacher in-service will fall normally on a Friday that coincides with the early

out at the elementary school. This is to provide the teachers the opportunity to have staff

development meetings/training for the safety and benefit of the children.

ABSENCE

No deduction or refunds will be made for absence the tuition contract guarantees a place

for your children and is the basis for staff salaries and expenses.

DROP-OFF AND PICK UP OF YOUR CHILDREN

It is very important for you to accompany your children when they arrive at the

preschool, the reason for this is that this is mandated by the State (State law requires

complete signatures on sign-in/sign-in out sheets).

There is an attendance sheet in the classroom. Parents must sign the children in for the

teacher to assume responsibility for that child.

This sign-in procedure gives parents a chance to share the preschool with your children.

It is important for the children to have time to point out friends, materials they work with,

and to see you interacting with their teacher.

Whoever is signing your child in or out must be a legal adult (18 years are over). An

older sibling that is not in adult must not sign children in or out.

AUTHORIZATION TO PICK UP YOUR CHILD

If someone other than a parent is dropping off or picking up your child, we need a note

from the parents, unless the individual dropping off or picking up is listed on the

emergency authorization form. We will release your child only to authorized persons.

They also must follow the sign-in/sign out procedures.

LATE PICK UP

We realize circumstances may cause you to run late from time to time, but you must try

to pick up your child by the end of the class. A telephone call will let us know you are

ruruling late so we can reassure your child. There will be $25 dollars late charge assessed

if the child is picked up late.

EMERGENCY INFORMATION

Incase of emergency it is important to maintain in your child's file:

- Current address

3

- Home, work, and cell phone numbers.

- Physician's and dentists names and phone numbers.

- Authorized persons who may take up your child.

Please notify the preschool immediately of any changes so we can keep your records

accurate, up to date, and reliable.

HYGIENE

Children will be reminded to wash hands each time they use the bathroom and before

snack. All staff will wear latex gloves while handling sick children or assisting in

personal needs of the child. All children must be potty train. No pull-ups are allowed.

Infrequent accidents are understandable at the beginning of the school year. If rate went

accidents continued to happen after the first few weeks of entry, children will be sent

home and asked to remain home until potty-trained.

ILLNESS POLICY

PLEASE, for the health of your child and others, do not send your child to school when

he/she is ill. The staff will assess the health of each child daily. Children with signs of

infection will not be accepted to school on that day. You will be directed to take them

home. Children must stay home if they have any symptoms listed below. Children must

be free of the symptoms for at least 24 hours before returning to school.

If your child will not be attending preschool for any reason, please phone 662-0372 by

8:30 AM so the teacher can be informed. No credit can be given for sick days.

SYMPTOM LIST

- Diarrhea

Fever of 100° or more. Temperature must be normal or 24 hours without the use

of fever reducers for 24 hours before returning to school.

Common cold (runny nose, vomiting mucus is the most common sign, also a

fever or loss of energy)

Cough with mucous secretion (wet, wheezy cough), which can spread a bacterial

or viral infection. A child experiencing the dry hacking of an allergy may attend

school. If there are any questions regarding symptoms, a doctor's clearance may

be required.

- A rash or skin infection with drainage. A child having dried lesions may attend

the school.

Vomiting recurring with fever.

Pink eye or conjunctivitis. The child must be on medicafion or 48 hours before

returning to school.

4

- Head lice (~~ww.health.vic.gov.au/headlice)

IF YOUR CHILD BECOMES ILL WHILE AT SCHOOL AND YOU ARE CALLED,

PLEASE COOPERATE BY PICKING HIM/ HER UP PROMPTLY. IF YOUR CHILD

HAS A TEMPERATURE OF 101 DEGREES OR MORE, WE ARE MANDATED BY

THE STATE OF CALIFORNIA TO CALL YOU AND HAVE YOU REMOVE THE

CHILD FROM THE FACILITY.

MEDICAL EMERGENCIES

Although we supervise the children in both indoor and outdoor activities, accidents

can, and do you happen. In the case of a minor injury we will administer aid to your

child and report the injury to you via an "ouch note" and/or phone call.

In the event that major first aid is required; every effort will be made to contact parents

first. If we are unable to reach the parents/guardians, the authorized persons on the

emergency form will be the next contact. In the event that the authorized person

cannot be reached, the school will seek the emergency care needed, this means calling

911 if the emergency requires it. Parents will be liable for expenses incurred.

DISCIPLINE

Discipline is considered to be a form of guidance rather than a form of punishment.

Our school is designed to be safe and encourage pro-social age appropriate behavior

from your children. The staff is trained to effectively use positive discipline

approaches such as redirection, role modeling and time-out in the thinking chair,

away from all the activity. When necessary, parents/ guardians will be informed to

keep you knowledgeable regarding the disciplinary action. Please, always feel free to

meet with the principal/ directory/ teacher to discuss another way to handle the

situation in question.

With the safety of the children and staff, any continuous negative behavior by a child

such as biting, hitting, or profane language will be evaluated. There will be a week

probation. To determine whether the child is suited for our program. If the child's

continuous disturbance is very serious and a threat to other children or staff, then

he/she will be asked to leave the preschool program immediately.

WITHDRAWAL FROM THE SCHOOL

If it becomes necessary to withdraw your child from ours school, we request you

notified in preschool office immediately. We require 30 day written notice of your

intent to withdraw. If we received the proper notification we will refund any unused

portion of your tuition.

5

MEDICATION

A permission to administer medication form must be completed by the

parent/ guardian each time medication is to be administered at school. Medication

will be administered only from the container it was purchased, according to the

directions on the label. Only prescription medication will be administered at school.

Medication will be stored in a locked container. The medication will have the child's

name of a Physician's name, and pharmacy on the label.

NUTRITION

The nutritional needs of young children are high because of the relatively high

demands of their growth. We always try to be aware of the nutritional value of the

food we eat some nutrition tips include: using natural sugars that can be found in

fresh fruit. Using a whole grain product such as wheat or bran muffins and cereal.

We concur also fresh vegetables and cheeses.

PARENT CONFERENCES

Parent conferences are scheduled at mid-year with your child's teacher. This is an

excellent chance for that parents and teachers to discuss the child's progress and to

share information about the home environments. A parent may request an

appointment with the teacher at any time to discuss your concerns. Please phone

preschool or e-mail the director is set up an appointment (662-0372;

jsalazarC~sjoacliim.org).

DRESS CODE

To help our students feel connected to the rest of the Saint Joachim student body and

for their safety, all St. Joachim preschoolers are asked to wear a uniform. The St.

Joachim Preschool uniform will be any clean white shirt, navy-blue pull-on shorts,

pants or sweatpants, athletic shoes and socks. No opened toed shoes. Please provide

simple, sturdy clothing that is free from complicated fastenings. Your child will be

encouraged to use the restroom by his/herself (under supervision).

Provide your child with warm clothing on cold days and appropriate clothing and

protects them from the sun in hot weather. Shoes are required, at all times, and they

should fit well and be comfortable. Open toed shoes such as sandals or jelly type

shoes are discouraged or safety reasons.

CHANGE OF CLOTHING

6

Please send a complete change of clothes marked with your child's name on them in

your child's backpack. These items will remain in the backpack in the event there is

an accident. Having a change of clothes readily available will save the child from

needless embarrassment if a situation should arise. Reminder: Please mark all coats,

sweatshirts, etc., with your child's name. Use a permanent laundry marker that will

not wash out.

Toys

Bringing toys from home often results in lost, broken, or misplaced toys for which the

school cannot be responsible. There will be sharing on the last day of the week in

which your child attends class. The toy/book/etc. is to be labeled and placed in the

sharing basket until sharing time and then to be put away in the child's cubby or

backpack until time to go home. We thank you for your cooperation and

understanding in this matter.

BIRTHDAYS

We celebrate birthdays during the snack time. You may send a nutritious snack for

your child and his/her classmates. We will add a birthday crown to the fun. The

birthday child is the flag holder/line leader/bell ringer for their special day. You will

be given a birthday time paper that will allow you to pick the date you want to

celebrate. If you do not receive this paper, please see the teacher as soon as possible

in the birthday month.

AMENDMENTS TO THE HANDBOOK

It is not possible to cover every situation in this handbook, further information on

school policies may be referenced in the St. Joachim School handbook. Therefore,

changes may be made throughout the year by the school principal in consultation

with the program director, and when necessary after consultation with the pastor.

Such changes will become effective after publication to families through

correspondence to the preschool families. When necessary, the director will use

his/her discretion and good judgment in making decisions that are for the welfare of

the students.

ADDITIONAL SCHOOL POLICIES~RULES

RESPONSIBILITIES OF THE STUDENT

1. Follow the rules of the school.

2. To respect authority of teachers and staff

3. To be polite to fellow students.

4. To respect the rights and property of others.

7

5. To do his or her best to make the time at school fund an exciting.

RESPONSIBILTTIES OF THE PARENTS

1. To keep the terms of agreement upon enrollment.

2. To send children in good health, cleanliness, and dress.

3. To write its school at the scheduled time.

4. To encourage good attitudes for learning and show respect to school authority.

5. To be responsible for misbehavior or damage to school property.

6. To work as a team with the director and staff directly involved with the child's

best interest in mind.

Again, thank you for choosing St. Joachim Preschool as your child's first school learning

experience. We are very excited for the future and looking forward to getting to know

your child we are preparing for wonderful school year.

St. Joachim Pre School /School

Permission Form for the Publishing of Student Photos

Name of Student: Grade:

Group Picture (Two or more students in the photo)

I understand that my daughter's or son's photograph (as part of a group photo) in connection with school activities, may be placed in printed materials or on the St. Joachim School website and that only my child's first name will be used.

Individual Picture i understand that, with my permission, my daughter's or son's individual photograph, in connection with school activities, maybe placed on the St. Joachim School website and that only my child's frst name will be used.

• 1/We do grant permission I/We do not grant permission Parent's Signature:

Publishing of Student Work

I understand that my daughter or son's artwork, writing or other school projects maybe considered for posting, for publication, or posting on the St. Joachim School Website, and that only my child's first name maybe used to identify his or her work.

By my signature below, I verify that I have read the above, and checked the appropriate box, to indicate my understanding of and permission related to the publishing of photos and/or student work of my child.

Parent's Signature: Date:

Printed name:

Permission to Publish_2019

STATE ar CALIFORNIA kE:ALTH At1D HUMAN SERVICES AC~£NCY

iI~ENTIFtCAT10N AND E~iERCENCY lt~FORMAT10fi! CHILD CARE CENTERS/FA~1LY CNtL.D CARE HOES To Be Completed by Parent or Authorized Representative

CALIFORNIA DEPARTN,ENT Of= SOCIAL SERVICES COMMUNITY CARE LiL`ENSING DIVISION

CHILD'S NA}.1E LA57 4~tDDLE

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NAMES OF PERSONS RUTH©RIZED TO TAKE CHILD FROM THE FACILITY (Cx~t1lD W1Li NOT SE AL.OWED T O LEAVE WiTfi ANY OTHER PERSON WfTtiOUT WRITTEN AUTFiORiZATION FROM PARENT OR AUTHORIZE£ REPRESENTATI~lE}

NAME RELATIONSHIP

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GNATUR£ OF PARENT OR AUTHORIZED REPRESENTATIVE GATE

TO BE COMPLETED 8Y FACILITY DIRECTORlADMINISTRATOR/FAMILY CHILD GARS HOMES LICENSEE ATE OF ADMISSION

C 700 {ENGISP) (5100)(CONfiDENTIALy

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STATE OFCJLIFOANIA ~ MEALTR AND HUMAN SERVICES AGENCY

PERSONAL RIGHTS Child Care Centers

CAIYGRNIA DEA/JrtMENT OF SDL4LL gERVICEg

Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers. (a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are

not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interterence with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.

To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardians) of the child.

Not to be locked in any room, building, or facility premises by day or night.

Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency.

(3)

(5)

(6)

(7)

THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

NAME

Community Care Licensing

ADDREss

1310 E. Shaw Avenue

ciTY

Fresno

9PGODE

93710 ~AREACODE?ELEPHONE NUMBER

(559)243-4583 I

D£TACH HERE

TO: PARENT/GUARDIAWCHILD OR AUTHORIZED REPRESENTATIVE: PLACE IN HILD'S FILE

Upon satisfaIXory and full disclosure of the personal rights as explained, complete the following acknowledgment:

ACKNOWLEDGMENT: I/We have been personally ativised of, and have received a copy of the personal rights contained in the California Code of Regulahons, Title 22, at the time of admission to:

(PRINr THE NAME OF THE FACILITY)

St. Joachim Preschool

(PRINT THE 1NME OF THE GMIID)

(&GNATURE OF THE REPREGENTATIVEIPARENTIGUARDIAN)

(TITLE OF THE REPPEEENTATIVEIPARENT/GWRDIAN)

I (PW NT THE ADDRESS OF THE FAG,UTY)

J310 North I Street, Madera CA 93637

r(pATE1 I

LIC 613A I6A81

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The t;alii~orrtia Departni~nt of Social Services ~~rorlts t:a protect tt~e safety of children ic7 child care by licensing child care centers and family child care homes. fur hig#pest priority is to be sure that cl►ildren are i€a safe and heaftt~y child care settings. California 1~3~^r requires a background check for any adult who owns, lives in, ar works in a licensedi child care Dome or center. Each of these adults must submit fingerprints sa t#~at a backgroE~nd check can be done to see if They tzave any history of crime. if we find that a person has been convicted of a criraae of#aer than a mi€aor traffic violation, helshe cannot work or' live i►a the licensed child care home car ce€ ter unless approved by t#~e Department. This aplatioval is called an exemption.

A person convicted of a c€~ita?r; such as rY~urder, rape, torture, kidnappinr~, crin ice of sexual violence cr mo(estatiorracainst children cannot ~ law ~e c~iv~n ,~n, exerttptiran that u~ou{d ~ailow them, ~, live jt~ ±~L work In a licensed child care home or center. if the crira~e v~ras a felony or a serious misdemeanor, the person must leave the facility while the request is being reviewed. if the crime is less serious, helshe tr=ay be al#owed to remain in the licensed child care home ar center w==ile the exemptionz request is being reviewed.

Now the Exemption Request is Reviewed We request infor~rration from po#ice departments, the F~! and the courts at3out tt~e person's record. L`Ve consider the type of crime, how. rr~atty crimes there were, how long ago the crime happened and whetter thc~ person has beers honest in what they laid us.

The person wlao needs the exemption must provide information about: ~-~.

. ~. u v l ~ t# 14 ..

• 11'~`hat they nave done to c#~ange their life ar€d abey the !aw

• ilyhether they are working, go'sng to school, or receiving train'€na

• l~`hether they (rave successfully completed a couns:~ling or rehabi#itation prograrrt

The person else gives us reference fetters from people w#ra aren't re#aced to them who .now about t~tei history and their life r:o~*~.

1rVe look at all these things very carefully irr real{ing our decision an exemptio}~s. 8y law this i€~farrnatior~ canto= tae shared ~vitYr t#?e public.

H©w to Qbtain IViore information ~s a parent qr authorized representative of a ch#ld in licensed child care, you have tf~e right to ask ttte licensed child care home car center whether anyone working or living there has an exemption. if you request this information, and there is a person wish an exer~nption, the child care home or center must tell you the person's name and how he or she is involved with the home or center and give you the name, address= and telephone number of the local licensing office. You may also get the person's name by contacting the local licensing office. You may find the address and phone Number an our website. The a:ebsite addc~ess is tazir:zrf4c..ds,.czh~=, et.goy:,~e~io.~~f~f ~~2a.=:z~

l.lC S8~ E (61G;} OFFICE COPY I !rave received a co~ay of =leis document: Signed Date

STATE OF GA4.<;~OR7Vtfi---h{F_AlTti atsJ iitJAdplti SERV<CES AGEi~lCY CAl.ifORNiA [1~PYlR1'iA€NT QF SdG1A~ SER'J•GES

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CAREGIVER E3ACKGROUND CHECK PRGCESS CALIFt3RNIA DEPARTIUIENT UI= SC3CIAL SERVICES

The California Department of Social Services works to protect the safety or' children in child care by licensing child care centers and family child care homes. Qur highest priority is to be sure that children are in safe and healthy child care settings. California taw requires a background check fdr any adult who owns, lives in, or works in a licensed child care home or center. Each of these adults must submit fingerprints so chat a background check can be done to see if they have any history of crime. If we find that a person has been convicted of a crime other than a minor traffic violation, he/she cannot work or live in the licensed child care home or center un{ess approved by the f~epartment. This approval is called an exemption.

A person convicted of a crime such as murder, rape, torture, kidnapping, crimes of sexual violence or molestation against~chifdren cartno~ by !aw be given an exemption that would allow th~ern, ~ own, five it ~ wot~~ ,i.,r a licensed child care home or center, if the crime was a felony ©r a serious misdemeanor, the person must leave the facility while the request is being reviewed. If the crime is less ser'sous, he/she may be allowed to remain in the licensed child care home or center while the exemption request is being reviewed.

How the Exemption Request is Reviewer 1/Ve request information from police departments, the FB! and the courts about the person's record. We consider the type of crime, how many crimes there were, how long ago the crime happened and whether the person has been honest in what they told us.

?'he person who needs the exemption must provide information about:

• The crime

UVhat they have done to change their life and obey tfie law

• Whether they are working, going to schoo#, or receiving training

~1lthether they have successfully completed a counseling or rehabilitation program

The person also gives us reference letters from people who aren't related to them who know about their history and their life now.

U11e look at all these things very carefully in making our decision on exemptions. By law this infom~ation cannot be shared with the public.

How tt~► t~btain More Information As a parent or authorized representative of a child in licensed child care, you have the right to ask the licensed child care home or center whether anyone wortcing or living there has an exemption. if you request this information, and there is a person with an exemption, the child care home or center must tell you the person's name and how he or she is involved with the home or center and give you the name, address, and telephone number of the l©cal licensing office. You may also get the person's name by contacting the local licensing office. You may find the address and phone number on our website. The website address is ~ttQ.Ilccl govls~c~~stma~~(stateshtrn

uc ss~~ ts~oz, PARENT'S COPY

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FI~YSICtAN'S R~Pt3RT--CHILD CARE CENTERS {CHILD'S PRE-ADMISSICN HEALTH EVA~UATIt~N~ _

PART A -= PARENT''S'CONSENT (To SE COMPLETEd BY PARENT

-. •• ,born is being studied €or r'eadiiie~s to enter • (NAME OF CHIf.Oj {BIRTH t?ATE)

St Joachim'I~reschool PreschoaC ~ .This Child Care CenterlSchool pro~,~des a program which extends From {NRrtiiE OF GtiiLD CARE CENTEfi15Ct•foUL) '

a.m./p.m. to a.m.tp.m. , days a week.. Please pravida a report are above-named child using t}~e €corm below. f hereby authorize release of medical information con#afned in this report #o the above-named Child Care Center, •

{S`tGNATUR3: QF FAFtEAI7 GUARDIAN. Or? CN:LD'S AUMORt2ED REPtii;SFJ1FATiYE► ETODAY'S DVITE)

PART 8 -- PHYSICIAN'S REP.C3RT (Tt3 BE GOMPLt~TED 8Y PNY5iCtAN~

Probterns or which you should be aware:

..............

Nearing; Allergies: med;rane:

' 1TisIaI7: lns2C1 stings:

~'aod:

LanguagalS}~eech~

~en,ai;

other t lnr.Iude behavioral concerru};

for, utsc~ntslE ~cptanati ons

Asthma:

1tVINiUN1ZATION Hl5T4RY; (Fill ou# or encioss California Immunization Record, PM-298.

• YACCtt~@

HATE EACH ~4SE WAS GIVEN 1 st 2nd 3rd 4th 5th

F't~tt0 (oPV OA tPVj ~ J ~ 1 1 ~ 1 1

t}TPti}TaPi t03~t3tN:RiA~IETAttt~.S ANU

s~rrrd ;►A~io>.~t~ ~ ~nS ~'~` ~r'~"'~ 1 1 1 1 1 / 1 1 1 1 ulatR tMEASLEs,It!{1L7Ps.ANORirHELiA1 / 1 1 1

tREC~ltilREO fOR CtYi.0 CARE QNtY) tats t;~~tvtrsctns ~ePt a~ 1 1 1 1 1 1 / !

NEPATt'TiS 8 ~ ~ ~ / ~ ~ „3

VARICEt.t..A tCliICKENPox) 1 I

SCREENING C?F TS RISK fiACT4RS {listing on reverse

~: Risk #actors not present; TB skin lest not required.

;,w Risk #actors present; Mantoux T8 skin test per€ormed previous posi~ve skin test documented). _.~.. Communical~e TS disease not present.

side)

(unless

I have have not

Physician: Address: Telephflne:

uc col texsa) {corfl~rtttal)

reviewed the above information with the parenUguardian.

Date of Physical Exam: Oate This Form Completed: 5ignatura

;~ Physician ~ Physiaan's Assistant : f .Nurse Practitioner PAGE r of z

STATE OF CykL.tFORNIA-^iiEJtt.TF! ANO NUA+WN 5ERViC;;5 AGENCY GALifpRNiA nEPARTIAENT OF SUGU1i. SERVICES CUMMUNITY DARE L3Gl:NStNG

CHILD'S PREADMISSIQN HEALTH H1STaRY--PARENT'S REP{)RT CHILD'S tJRME

6`ATNER"S NAM£

SEX BIRTH C}AT£

CFOES fiAT}i£it LIVE IN HCSME W:Tri CHCL~

MOTHER'& NAASE DUES MOTHER ltl~~£ tN Nt?ME W17H CHtkt7+

i5 Jt•iAS CHILD BcEN UNAER REGULAR SUPERVISiC3N T3F Pf°lYSrlClAN? DATE Of LAST PHYSICAUMEOtCAL EXANlt.ATiGN

DETI'EI`CJPMENTKt" Ht'SZ OKY-_ (•For infants an"`8`p`resc -aye r —on-7'Y~" WALKED AT4 ~ BEGAN TALKING A7*

ML7NTN5 1tAONTHS 7016E:T TRAINING SYARTEDAT•

MtUN7NS

PAST ILLNESSES --Check ittr~esses that child has had and specify a~proxtmata dates of iitnessas: DATES PATES OtiT~S

Chicken Pox ,....; (diabetes C7 Poiiomyetitis

Asthma Epilepsy E J Ten-Day Measles {Rubeoia)

Rheumatic Fever C~ Whooping cough t~ Three-Day Measles Q Hay Fever C7 Mumps {Rubella) SPECIFY ANY OTHER S£ftK3US UR SEY£RF LLNESSE5 C)R ACGSDENTS

~.

i~ ~ NQYY MANY iN UtST YEAR? UpES CHILD HAVE FRE(7UGNT CUI.DS? I..... 1'E5 („„; NU

LIST ANY ALLERCrtES STAFF SFt(?tJLO 8E AWARE C+f

DAILY ROUTINES ('`t`or inFanrs and pr~sschocat-,ache children onto.} WHAT TIME DOES CHILD CET L'Py• ~--71ST-tvNAT TIME OOr`.S CHILD Gq TU 6ER}?•

OOfiS CHAD SLEEP DU1tiNG T11E f?AY?•

DOES CHILD uLc[f"'>,YELL?•

_...... I WET PATTERNS BR[AK£ASt {VYttelt dC?d!S Ghiki usLlellly EIBt #Cvr thB88 TTl68L3?} IUNCN

E?~INE.R

WHAT AR£ 1JSUAL EATING rsOLrRS~ 8REAKFAST

LUNCH

C)NOMER

ANY FOOD (3lS:tK£5?

IS CHILD TOILET 7i$A!N£Cs4• 3F Y£5, AT Wf4~1T STAGE'•

C`~ vEs C7 No i Wt3Rn USED I:TaR 'BOWEL QADVEM£NT-*

ANY EATING PROBL£r>157

w ARE 801KEL MUVE~tENTS REiaULARY•

i_.mi 'tES ~ NC3

wo>;D usEl~ FOR URlNATKaN•

I YYrIA?' 4S USUAL TiME7•

tM:RENT ~ EYAL43AT10N OT` GisiL D'S N£ALTH

LS >wttiLD PR}rSENTLY UAILk:R A TX3s:.Tgrt';4 CAxtf;:? ~ YES. NAME C«f L~L3L.TCFY

~---' YES ~~ fi2C3

DnES CHILD USE ANY SPEC7Al C)EVtCE($~' 3F

YES, WHAT KINC

CSQkS CHILD ?AICE PRESt~xtF0E0 NIi:DlGATt631.t5}? ~ tF YE$, YsHAT KIND ANg At`tY SI£3E EFFECTS: ~. ~._s

Y£S ~..3 !kv

DOES CHILD t1SE ANY SPECIAL DEYIfrE;Sj A7 HOAAE?~ NF YES, WHAT KIND

j ~-+ Y£S ~--~ NQ ~

ARENT'S EYALUATIUN UT GN.ILSD'S P£RS~C>I+iALITY .

fttJW DOES GHlLU C,ET ALONG WI"TH PARfiNTS. BRQ7Nci25. SISYCRS AND QT}ifR CItN Uf?EN~

riAS THE CHILD riAD GROUP PLAY EXPER+LNf E5?

nOES THE CNlLU HAVE ANY St~EC:tAI PRt?BLE~IS`FEAf25~:L^'6GS'%{F:XPLAiN j

WHAT IS THE PLAN FOR GARS WHEN TttE CHILD tt3 ILL?

f2EA6CiN fiOR TiET]UESTING DAY CA32E PLACEMENT

PARENT'S 51GNATURt DATE

i.I+C 702 (7199) ~CDNFtDENT1AL~

STATE OF CYIrORNIA_FIE/~LT1aN0 NULIIJ! SEFNCFS AGENCY CNJEONNM DEMRrMe1T OF SOCIAL SERVICE6 CdNIUNITV CARE LILBi^WNG OINSIp~

CHILD CARE CENTER NOTIFICATION OF PARENTS' RIGHTS

PARENTS' RIGHTS As a ParenVAuthorizetl Representative, you have the right to:

1. Enter and inspect the child care center without advance notice whenever children are in care

2. File a complaint against the licensee with the licensing office and review the licensee's public file kept by the licensing office.

3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years.

4. Complain to the licensing office and inspect the child care center without discdmination or retaliation against you or your child.

5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order.

6. Receive from the licensee the name, address and telephone number of the local licensing office.

Community Care Licensing Licensing Office Name:

Licensing Office Address: 1310 E. Shaw Avenue, Fresno CA 93710

Licensing Office Telephone #: (559) 243-4583

7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office.

8. Receive, from the licensee, the Caregiver Background Check Process form.

NOTE: CALIFORNIA STATE LAW PROVIDES 7TNT THE LICENSEE MAY DENYACCfSS TO THE CHILD CARE CENTER TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE. For Ma DepartmMl d Juallee "Registered Sex OHeTNier"database, go fo Nrww.megansisw.ca.gov

LIC 993 t9A31 (DeteU Mere. Gies UPPer POr9gn 1O Parents)

ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS' RIGHTS /Parent/Authorized Representative Signature Required)

I, the parenUauthorized representative of have received a copy of the "CHILD CARE CENTER NOTIFICATION OF PARENTS' RIGHTS" and the CAREGIVER BACKGROUND CHECK PROCESS form from the licensee.

Name of Cftlltl Cere Center

Signature (ParenVAulhor¢eE Repeserlletive) Date

NDTf: This Acknowledgement must be kept in child's /i!e and ecopy o/ the Noti/ication given to

parenf/authorized representative.

For the Department of Justice "Registered Sex ONender"database go to www.rneganslaw.ca.gov

i Ic 9n ISAeI