Pre-K Counts/Headstart Program Enrollment

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

ADDRESS

TELEPHONE NUMBER WHEN CHILD IS IN CARE

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

CHILD PICK-UP AUTHORIZATION

I,

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

Agreement Form

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

Name of Child

Type of Service

PreK Counts Headstart ONLY (No Charges to families in the program)

Before Care

After Care

Before and After Care

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 $25-PKC or Before care ONLY AFTER 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)

#5: CHILD'S DIETARY or FOOD RESTRICTIONS FORM

Child's Name

Date of Birth

Dear Parent/Guardian, The Child and Adult Care Food Program (CACFP) provides a daily nutritional breakfast, lunch and snack for your child at no cost to families. A monthly menu, posted in each location, lists the foods and beverages that your child is offered at each meal. The Office of Early Childhood Education recognizes the fact that certain foods, due to medical, religious or other reasons, are restricted from some children's diets. Please tell us about your child. This information will be shared with your child's nutritional, health and instructional staff. If your child has a non-disabling dietary restriction, efforts will be made to provide your child with an allowable substitution,

If your child has a food allergy or medical dietary concern that restricts his/her diet, the enclosed Medical Plan of Care Form for the Child ond Adult Care Food Program (Pages 33-34) must be completed by an appropriate health care professional and submitted with your child's Preschool Application. If your child has a food allergy which requires the administration of an EPI-PEN, Benadryl or other medication, please let us know immediately so that we can begin the process required to train the preschool staff.

Please check one box and complete as necessary — use additional paper if needed

At this time, my child does not have a dietary or food restriction.

My child has the following dietary or food restriction(s)

1. Name of restricted food

Reason for restriction

Religious

Other

Please Specify

Medical — please indicate reaction and treatment

Please Specify

2. Name of restricted food

Reason for restriction

Religious

Other

Please Specify

Medical — please indicate reaction and treatment

Please Specify

The information on this form is true to the best of my knowledge. I will inform my child's teacher if any of this information changes.

Signature of Parent/Guardian

Date

#2: CHILD’S MEDICAL CONCERNS FORM

Child's Name

Date of Birth

Dear Parent/Guardian, The Office of Early Childhood Education recognizes the fact that some children have a medical condition that requires prescribed medication. When the prescribed medication is to be administered during preschool hours, a representative from Early Childhood Health Services, with written permission, will train the staff at your child's preschool to administer the medication to your child. Written permission is given by submitting form MED-1: Request for Administration of Medication, completed by you and your child's health care provider for each medication. At no time will medication be given to your child without a completed MED-1.

Please check one box and complete as necessary - use additional paper if needed

At this time, my child does not have a medical condition

My child has the following medical condition(s): A representative from Early Childhood Health Services may contact you for more information

1. Diagnosis or medical condition

Does not require medication to be administered

Requires medication to be administered DAILY Requires medication

Requires medication to be administered AS NEEDED

Medication name, dose and times

2. Diagnosis or medical condition

Does not require medication to be administered

Requires medication to be administered DAILY

Requires medication to be administered AS NEEDED

Medication name, dose and times

The information on this form is true to the best of my knowledge. I understand that it is my responsibility to immediately inform my child's teacher or Early Childhood Health Services if there is a change to the information indicated above.

Signature of Parent/Guardian

Date

Little People’s Village

#8 VERIFICATION of INFORMATION FORM

Read the following statements and sign where indicated.

My/Our signature(s) below indicate that:

The information I/we have provided on all of the forms in my/our child's Preschool Application is accurate and complete. I/we have signed all application forms where indicated and have included copies of all required supporting documents. If any of my/our information is false, my/our participation in the preschool program may be terminated and I/we may be subject to legal action.
I/We understand that:
1. The information contained in my/our child's Preschool Application will be held in strict confidence within The School District of Philadelphia and affiliated Community Nonprofit Partner Agencies that have been determined to be school officials under the Family Educational Rights and Privacy Act with legitimate educational interests as part of The School District of Philadelphia's preschool program.
2. Completing and submitting a Preschool Application does not guarantee that my/our child will be accepted to a preschool program.
3. Before my/our child's first day in preschool:
  1. I/We will attend an orientation meeting and an individual conference with my/our child's teacher and will receive a Parent Handbook.
  2. If my/our child's physical and/or dental exam dates are more than twelve (12) months old, I/We will be required to submit an up-to-date Child Health Assessment/Physical Exam Form, including a current immunization record and/or Child Dental Health/Dental Exam Form.
  3. I/We may be required to re-verify my/our Philadelphia, PA address, family income and/or monthly benefits.
  4. I/We will be notified if additional forms and/or documents are needed and will submit them as necessary.
During the time my/our child is enrolled in preschool:
1. S/He will attend every school day, his/her health permitting.
2. S/He will be escorted to and from school by an individual who is at least eighteen (18) years old.
3. S/He will be able to use the toilet with minimal adult assistance
4. I/We will abide by all program policies stated in the Parent Handbook and will adhere to the scheduled arrival and departure times for his/her location.
5. I/We will keep my/our child's information current and inform his/her teacher and the Office of Early Childhood Education of any changes.
6. I/We will always make sure my/our child's teacher has an active telephone number from within the Philadelphia calling area for me/us so that I/we can be contacted should the need arise.

Child’s Name

Date of Birth

Signature of Primary Parent/Guardian

Date

Signature of Secondary Parent/Guardian

Date

Pre-K Counts/Headstart Program Enrollment

EMERGENCY CONTACT PARENTAL CONSENT FORM

CHILD PICK-UP AUTHORIZATION

Agreement Form

Little People’s Village

CHILD and FAMILY INFORMATION FORM

Little People’s Village

#1 CHILD and FAMILY INFORMATION FORM

#1 CHILD and FAMILY INFORMATION FORM

Section 4: SECONDARY PARENT

An adult who shares in the care of the child.

Section 5: FAMILY MEMBERS

List your name, the name(s) of your child(ren) and the names of all other adults and children who live with you in your home. Use additional paper if needed

Section 6: FAMILY INCOME

Section 7: SIGNATURES

#5: CHILD'S DIETARY or FOOD RESTRICTIONS FORM

#2: CHILD’S MEDICAL CONCERNS FORM

Little People’s Village

#8 VERIFICATION of INFORMATION FORM

2022-2023 PA Pre-K Counts Enrollment Form

(This information is confidential to the PA Pre-K Counts program)

Other Child Eligibility Risk Factor Criterion (Must check all that apply):