Childcare application

EMERGENCY CONTACT PARENTAL CONSENT FORM

55 PA CODE CHAPTERS 3270.124(a)(b), 3270.181 & 182, 3280.124(a)(b), 3280.181 & 182, 3290.124(a)(b), 3290.181 & 182

CHILD'S NAME

BIRTH DATE

ADDRESS

MOTHER'S NAME/LEGAL GUARDIAN

HOME TELEPHONE NUMBER

E-MAIL ADDRESS

MOBILE TELEPHONE NUMBER

ADDRESS

BUSINESS NAME

BUSINESS TELEPHONE NUMBER

ADDRESS

FATHER'S NAME/LEGAL GUARDIAN

HOME TELEPHONE NUMBER

E-MAIL ADDRESS

MOBILE TELEPHONE NUMBER

ADDRESS

BUSINESS NAME

BUSINESS TELEPHONE NUMBER

ADDRESS

EMERGENCY CONTACT PERSON(S) NAME

TELEPHONE NUMBER WHEN CHILD IS IN CARE

PERSON(S) TO WHOM CHILD MAY BE RELEASED NAME

TELEPHONE NUMBER WHEN CHILD IS IN CARE

ADDRESS

NAME OF CHILD'S PHYSICIAN/MEDICAL CARE PROVIDER

TELEPHONE NUMBER

ADDRESS

SPECIAL DISABILITIES (IF ANY)

ALLERGIES (INCLUDING MEDICATION REACTIONS)

MEDICAL OR DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION

MEDICATION. SPECIAL CONDITIONS

ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD

HEALTH INSURANCE COVERAGE FOR CHILD OR MEDICAL ASSISTANCE BENEFITS

POLICY NUMBER (REQUIRED)

PARENTS SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

OBTAINING EMERGENCY MEDICAL CARE

ADMIN. OF MINOR FIRST - AID PROCEDURES

WALKS AND TRIPS

SWIMMING

TRANSPORTATION BY THE FACILITY

WADING

PERIODIC REVIEW

SIGNATURE OF PARENT OR GUARDIAN

DATE

SIGNATURE OF PARENT OR GUARDIAN

DATE

Agreement Form

55 PA CODE CHAPTERS 3270.123&.18l(C); 3280.123&0l81 (c); 3290.123&.18I (c)

Name of Child

Fee Amount $

Per-day-Week Week

Day payment to be Made Monday

Type of Service:

InfantYoung ToddlerOlder ToddlerPreK Counts/Headstart ONLY (NoCharges to families in the Program)Before CareAfter CareBefore and After CareSummer Camp

Services to be provided as part of the daycare fee (examples; transportation, care, meals, etc.)

Breakfast, Lunch, Snack, Child Service Report/ Assessments, Parent Conferences, Themed weekly curriculum, Parent Resources, and School Trips with Transportation for PreK Counts and Head Start Children

Child arrival time

Child departure time

Person(s) designated by parent to whom child may be released

Late fee's
$10-5:31pm-5:36pm- $1.00 a min-After 5:36pm PKC and HS - $25 at 3:01 pm

Extra services to be provided at an additional fee if applicable

I, the parent/guardian;

Received complete written program information at the time of enrollment (S 3270.121, 3280.121 ,3290.121)
Agree to update the emergency contact/ parental consent for information whenever changes occur or every 6 months at a minimum. (S 3270.124, 3280.124, 3290.124)

Signature of Director

Date

Signature of parent or guardian

Date

Date of child’s Admission

Date of child's Withdrawal

Periodic Review

Signature of parent or Guardian

Date

PLEASE PUT YOUR INITIALS NEXT TO WHAT IS APPLICABLE FOR YOUR CHILD:

Date

Parent Signature:

Orientation-

I understand that I MUST attend a mandatory orientation before my child can start. The date and time will be scheduled by LPV.

Date

Time

IEP/IFSP

Your child's growth and development is measured with developmental assessments. If your child currently has an IEP/IFSP, it would be beneficial to share a copy of this plan with us so we can work together to ensure that the guidelines are put into practice. You do not have to provide this information if you do not wish to do so.

I am providing a copy of my child's lEP or IFSP.

I am not providing a copy of my child's IEP or IFSP and/or this is not applicable to my child.

PICTURE

Occasionally the Center staff or approved visitors take pictures of or videotape the children. You can be sure that we take precaution for our children and these pictures (still or moving) maybe used to publicize and promote Center activities or events. Pictures may appear in local newspapers, center brochures, or on television. No additional notice may be given of picture-taking sessions.

I doI do not give permission for my child to be photographed or videotaped while at the Center or on Center-sponsored field trips for purpose of promoting the Center and its activities.

LPV TRIP SHIRT

We also take the children out on trips to local parks or cites where there may be groups of people. For such occasions, at the time of registration, children are given a t-shirt that has our school logo and telephone number on it.

I receivedI did not receive my child's School shirt at time of registration.

TRANSFERRING RECORDS

If you would like for your child's records to be transferred, we would need 72 hours’ notice. We would also need a written letter or form stating which records, why you want them to be transferred, and where you would like them to go.

I agreeI do not agree to give 72-hour notice.

My Child:	Yes/No	Comments
Wears Diapers or Pull-ups	YesNo
Wears Glasses or has a lazy eye, crossed eye, wandering eye or other eye condition	YesNo
Has ear tubes, hearing loss, wears a hearing aid, has a history of ear infections or other ear conditions	YesNo
Has excessive colds, sore throats, coughing episodes, snores loudly	YesNo
Has a history of asthma or bronchitis	YesNo
Has a heart murmur, a resolved heart murmur, rheumatic fever or other heart conditions	YesNo
Has a history of anemia, sickle cell disease, elevated lead level	YesNo
Has G6PD, hemophilia, or other blood conditions	YesNo
Has an umbilical or inguinal hernia	YesNo
Has reflux, stomach pain, diarrhea, constipation, trouble urinating, urinary tract infection or kidney disease	YesNo
Has a feeding tube	YesNo
Has diabetes (If yes, please indicate Type I or Type Il)	YesNo
Has rashes, eczema, hives, boils	YesNo
Has neuropathy, muscle tics, spina bifida, muscular dystrophy, cerebral palsy	YesNo
Wears leg braces, uses a cane, walker, or wheelchair	YesNo
Has/had polio, chicken pox, measles, mumps, scarlet fever, whooping cough	YesNo
Experiences car sickness	YesNo

CHILD PICK-UP AUTHORIZATION

authorize Little Peoples Village to release my child(ren) to the person (s) designated. This is in consonance with Little Peoples Village Emergency Contact/Parental Consent Form.

Student's Name

Designated Custodian(s) Name & Relationship

Your Signature

Relationship

Date

Print Name

Address

Home Phone

Work

Cell

Note: Parents and guardians should designate themselves and designated custodians.

Friends, neighbors and other relatives may also be designated.

PLEASE PRINT CLEARLY

Emergency Operation Plan

To the Parent/Guardian

This letter is to assure you of our concern for the safety and welfare of children attending Little Peoples Village. Our Emergency Operations Plan provides for response to all types of emergencies. Depending on the circumstance of the emergency, we will use one of the following protective actions:

Immediate Evacuation Students are evacuated to a safe area on the grounds of the facility in the event of a fire etc.
In-place Sheltering Sudden occurrences, weather or hazardous materials related, may dictate that taking cover inside the building is the best immediate response.
Evacuation Total evacuation of the facility may become necessary if there is a danger in the area. In this case, children will be taken to Relocation Facility at Good Shepard Church 6439 N 65' St Phila., Pa 19151.
Modified Operation May include cancellation/postponement or rescheduling of normal activities. These actions are normally taken in case of a winter storm or building problems that make it unsafe for students (such as utility disruptions) but may be necessary in a variety of situations.

Please listen to Channel 6 ABC News for announcements relating any of the emergency actions listed above.

We ask that you not call during the emergency. This will keep the main line telephone free to make emergency calls and relay information. We will call you to let you know that we've taken one of these protective actions. We will also call you when we've resolved the situation and it's safe for you to pick up your child.

The facility director may provide an alternate phone number (i.e. cell phone number, etc.) to call in an emergency event. All center calls will be transferred to the location of Good Shepard Church.

The form designating persons to pick up your child is included with this letter for you to complete and have returned to the day care center no later than one week. This form will be used every time your child is released. Please ensure that only those persons you list on the form attempt to pick up your child.

I specifically urge you not to attempt to make different arrangements during an emergency. This will only create additional confusion and divert staff from their assigned emergency duties.

In order to assure the safety of your children and our staff, I ask your understanding and cooperation. Should you
have additional questions regarding our emergency operating procedures contact the Director at LPV 215-474-3011.

Thank you,

LPV Management

CHILD HEALTH REPORT

(55 PA CODE §§3270.131, 3280.131 AND 3290.131)

CHILD’S NAME: (LAST)

CHILD’S NAME: (FIRST)

PARENT/GUARDIAN:

DATE OF BIRTH:

HOME PHONE:

ADDRESS:

CHILD CARE FACILITY NAME:

FACILITY PHONE:

COUNTY:

WORK PHONE:

I authorize the child care staff and my child’s health professional to communicate directly if needed to clarify information on this form about my child.

PARENT’S SIGNATURE:

DO NOT OMIT ANY INFORMATION

This form may be updated by a health professional. Initial and date any new data. The child care facility needs a copy of the form.

HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND DIAGNOSIS/TREATMENT IN EMERGENCY (DESCRIBE, IF ANY):

DESCRIBE ALL MEDICATION AND ANY SPECIAL DIET THE CHILD RECEIVES AND THE REASON FOR MEDICATION AND SPECIAL DIET. ALL MEDICATIONS A CHILD RECEIVES SHOULD BE DOCUMENTED IN THE EVENT THE CHILD REQUIRES EMERGENCY MEDICAL CARE. ATTACH ADDITIONAL SHEETS IF NECESSARY.

CHILD’S ALLERGIES (DESCRIBE, IF ANY):

LIST ANY HEALTH PROBLEMS OR SPECIAL NEEDS AND RECOMMENDED TREATMENT/SERVICES. ATTACH ADDITIONAL SHEETS IF NECESSARY TO DESCRIBE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHILD, INCLUDING INDICATION OF SPECIAL TRAINING REQUIRED FOR STAFF, EQUIPMENT AND PROVISION FOR EMERGENCIES.

IN YOUR ASSESSMENT, IS THE CHILD ABLE TO PARTICIPATE IN CHILD CARE AND DOES THE CHILD APPEAR TO BE FREE FROM CONTAGIOUS OR COMMUNICABLE DISEASES?
NoYes
IF NO, PLEASE EXPLAIN YOUR ANSWER:

HAS THE CHILD RECEIVED ALL AGE APPROPRIATE SCREENINGS LISTED IN THE ROUTINE PREVENTIVE HEALTH CARE SERVICES CURRENTLY RECOMMENDED BY THE AMERICAN ACADEMY OF PEDIATRICS? (SEE SCHEDULE AT WWW.AAP.ORG)
NoYes

NOTE BELOW IF THE RESULTS OF VISION, HEARING OR LEAD SCREENINGS WERE ABNORMAL. IF THE SCREENING WAS ABNORMAL, PROVIDE THE DATE THE SCREENING WAS COMPLETED AND INFORMATION ABOUT REFERRALS, IMPLICATIONS OR ACTIONS RECOMMENDED FOR THE CHILD CARE FACILITY.

VISION (subjective until age 3)

HEARING (subjective until age 4)

LEAD

RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD’S IMMUNIZATION RECORD

IMMUNIZATIONS	DATE	DATE	DATE	DATE	DATE	COMMENTS
HEP-B
ROTAVIRUS
DTAP/DTP/TD
HIB
PNEUMOCOCCAL
POLIO
INFLUENZA
MMR
VARICELLA
HEP-A
MENINGOCOCCAL
OTHER
MEDICAL CARE PROVIDER:			SIGNATURE OF PHYSICIAN, CRNP OR PHYSICIAN’S ASSISTANT TITLE:
ADDRESS:			PHONE:
LICENSE NUMBER:			DATE FORM SIGNED:

I, certify that I have read, understand, and agree to comply with the provisions listed herein.I acknowledge that failure to act in accordance with the provisions listed herein, or with any other policy or procedure outlined by Little Peoples Village will result in termination of services. I acknowledge that care for my child will be terminated if it is determined that my actions, or lack of action unnecessarily exposes another employee, child, or their family member to COVID-19.

Child's Name:

DOB:

Parent's Name:

Parent Signature:

Date:

Parent's Name:

Parent Signature:

Date:

Management Team Witness:

Date:

Re-Opening LPV

Due to restrictions still in place, we will reopen at 75% capacity in each room. When instructed to and all safe measures are taken, we will open with full operation hours. It's impossible to have the same staff care for the same kids throughout the day without mixing up children and teachers from other classes so changes were made for everyone's safety.

New Temporary hours

We will be reopening Monday -Friday 7:30am-5:30pm. With only serving children no longer than 9 hours a day.

Same staff and same classroom

To help minimize interactions throughout the building, we are having all classrooms open throughout the day
from open to close. This will help isolate any spread if a child or staff get sick. We will not be mixing the children or staff in different classrooms at any time. Same staff with same kids! Due to this guideline. We had to lower our hours to accomplish this goal. We will be open from 7:30-5:30pm and children can not exceed a 9hr period in a day. We also put a third teacher in each classroom to make sure all hours are covered, with same teachers, for the duration of the day.

Lower enrollment

We wil6 lower our enrollment to we feel it is safe per CDC guidelines to go to regular capacity. By limited capacity, we hope this will lower the chance of covid spreading.

Drop off/pick up and labeled Waiting Spots

Designated drop off/pick up for children will be in rear entrance yard. This will allow adequate space for social distancing. We will have markings 6 feet apart near entrances so families know where to stand safely from one another.

Only Students and Staff Allowed Inside

Each person who enters a facility increases the chances of COVID-19 transmission, so it is a good idea to keep families outside and not allow any visitors.

Designated Runner

Assign the same staff members the responsibility of greeting families and walking each child to their classroom.

Health Screening Questionnaire

Before a child is allowed inside, parents answer a questionnaire to ensure they do not have any signs of COVID-19. Here is a sample questionnaire you can use:

Do you or your child or any member of your household have any of the following symptoms?
Fever (37.8C 100.4F Or Higher)
New/Worsening Cough
Shortness of Breath
Sore Throat
Difficulty Swallowing
Loss of Taste or Smell
Nausea/Vomiting, Diarrhea, Abdominal Pain
Runny Nose, or Nasal Congestion (In the absence of underlying reasons such as Seasonal Allergies, Nasal Drip, Etc.) Unexplained Fatigue/Malaise/Myalgia
Chills
Headache
Conjunctivitis (Pink Eye)
Lethargy/Difficulty Feeding in Infants

Have you had contact with anyone with acute respiratory illness or who travelled outside of (country) in the last
14 days?

Have you had close contact with someone who has been diagnosed with COVID-19?

If you answered YES to any of these, DO NOT enter. Your child cannot be permitted to enter to ensure the safety of everyone. Contact your health care provider.

Temperature Checks

Check each staff and child's temperature using an infrared contactless forehead thermometer to ensure they do not have a fever before entering the building. This will be done at least twice a day to ensure temperature doesn't go up during the day.

Wear Masks

Ensure that every adult is wearing a face mask. Children under 3 years old should not wear face masks. There are mixed opinions on whether older children should wear masks and so unless legally required it is up to your discretion whether children should be required to wear them.

Contactless Check-in

Our staff member will check in/out children in for attendance on our childcare app daily.

Hygiene Station

Hand sanitizing station at the entrance of the building for all staff, parents and children to use before interacting with one another. Frequently washing hands with soap and water.

Indoor and Outdoor Play

Gross Motor activities are still included in your child's daily schedule but have been modified. Toddlers will only use the indoor play space which will be sanitized between each classroom use. Preschoolers and School Age children will use the outdoor play yard and equipment which will also be sanitized after each class use.

Scheduled Appointments

We will only take scheduled meetings with the directors, teachers and management. You must contact the front desk to schedule a meeting if necessary, to discuss any concerns. We want to ensure your safety as well as ours.

Outside Food (12 months and up) and Personal Items

Little Peoples Village has had a NO OUTSIDE FOOD Policy since September 2019, this will be strictly enforced as we reopen. NO food from outside is allowed in the center at this time. All personal items to include "inside
shoes", additional clothing, blankets and crib sheets are to be brought upon return and LEFT at the center. We will wash and sanitize all personal items weekly. INFANTS: You still must bring pre-made bottles and baby food daily if applicable.

If my child has any of these signs of COVID-19, I will not send him/her back to school or camp until:

• My child tested negative for COVID and is otherwise well enough to go back to school or camp OR

• A healthcare provider has seen my child and documented a reason for the symptoms other than COVID
OR

• All are true: 1) at least 10 days since the start of symptoms AND 2) fever free off anti-fever medicines for 1 day AND 3) symptoms are getting better.

If my child is diagnosed with COVID-19, I will not send him/her back to school or camp until the following:

• It has been at least 10 days since my child first had symptoms
AND

• My child has had no fever off anti-fever medicines (ex: Tylenol, Ibuprofen) for 1 day AND

• My child’s symptoms are getting better

If someone in my household is diagnosed with COVID-19 or my child is exposed to COVID-19, I will keep him/her home for 10 days.
If someone in my household develops any symptoms from the table above, I will get them tested for COVID-19. Find your nearest testing site here: https://www.phila.gov/testing. If that person tests positive, I will keep my child home for 10 days.

Child’s name:

Parent/guardian name:

Parent/guardian signature:

Date: