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
SIGNATURE
DATE
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.
Designated Custodian(s) Name & Relationship
Your Signature
Relationship
Date
Print Name
Address
Address
Home Phone
Work
Cell
Note: Parents and guardians should designate themselves and designated custodians.
PLEASE PRINT CLEARLY
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.
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.
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.
My Child:
No
Yes
Comments
Wears Diapers or Pull-ups
Wears Glasses or has a lazy eye, crossed eye, wandering eye or other eye condition
Has ear tubes, hearing loss, wears a hearing aid, has a history of ear infections or other ear conditions
Has excessive colds, sore throats, coughing episodes, snores loudly
Has a history of asthma or bronchitis
Has a heart murmur, a resolved heart murmur, rheumatic fever or other heart conditions
Has a history of anemia, sickle cell disease, elevated lead level
Has G6PD, hemophilia, or other blood conditions
Has an umbilical or inguinal hernia
Has reflux, stomach pain, diarrhea, constipation, trouble urinating, urinary tract infection or kidney disease
Has a feeding tube
Has diabetes (If yes, please indicate Type I or Type Il)
Has rashes, eczema, hives, boils
Has neuropathy, muscle tics, spina bifida, muscular dystrophy, cerebral palsy
Wears leg braces, uses a cane, walker, or wheelchair
Has/had polio, chicken pox, measles, mumps, scarlet fever, whooping cough
Experiences car sickness
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
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
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
ENROLLMENT AND "GETTING TO KNOW YOU" MEETING GUIDLINE
Child's Name:
Names of Meeting Attendees:
Meeting Dates: Enrollment:
Getting to Know You:
If "Getting to Know You" meeting was refused:
1. Date of refused by parent:
2. Attach a list of the information that you shared in written form.
Questions that might be asked at enrollment.
Family Composition Questions
Who lives with the child? (Names and relationship to child)
Does your child have any parent that does not live in the home? Yes/No Does your child visit this parent? Yes/No Are there any custody issues that we should discuss?
Does your child have any siblings? (Names and ages)
Does your family have any pets?
Is there any other information about your family's composition that you would like to share?
Child Information
Has your child been in an early learning program or child care before?
If yes, would you share some information with us? (Where? When? For how long?)
What kind of care (family day care home, relative/neighbor care, group, or center)?
Is there a reason for leaving that program that you would like to share with me?
Do you have any of your child's records from that program?
How did your child react to other children and adults?
What do you think will happen the first day your leave your child with us?
Does your child have any imaginary friends?
Are there any special problems or fears that we should know about?
Does your child do any of the following:
Nail biting? Yes/ No Thumb sucking? Yes/ No Stuttering?
Any special needs (medical, developmental, social, or mental health?
Do any of these special needs require special care by our teachers?
Does your child have any of the following allergies:
Food?
Environmental?
Medication?
How are your child's allergies tested?
Do you have any special medical or dietary information for management in an emergency situation (medicine to keep on hand, people to call, etc.)? Any other medical or special needs?
Describe your child's schedule:
Normal bedtime, waking time, nap time and duration
Meal times
Does your child have a different schedule at any other child care setting (babysitter, relative/neighbor care, school)?
Regarding toilet habits, what words does your family use for bowel movements and urination?
Any terminology for private parts?
Is your child toilet trained?
Does your child need to be reminded to go to the toilet during waking hours?
Is there information that will help us make the first few days in our program easier for your child?
"GETTING TO KNOW YOU" MEETING
Questions for the Parent
What are your expectations of our program?
Is any particular aspect of the education program especially important to your child/family?
Is there any information about your family's culture, ethnicity, language, or religion that is important for us to know? Would you and/or your family like to be a resource for any cultural awareness activities?
Are you willing to be a volunteer in our classroom?
Are there any other ways you would like to be involved?
Are there any other talents or interests you would like to share with us?
What times are best for us to reach you and/or for you to come in for parent conferences?
Tell me about your child's favorites (ex toy, games, food, etc.)
Has your child talked to you about his or her experiences in our program so far?
Is he/she positive about the program, other children, and the teaching staff?
If not, how do you think we can make your child's experience better?
Are there any ways that we can improve communication with you about your child's experiences?
Parent/Guardian
Handbook Acknowledgement
Parent/legal guardian first and last name
Chi1d' s first and last name
Agree to abide by the Center's Policies and Procedures
Have read this handbook in its entirety.
I agree to pick my child up on time.
I understand that tuition is due every Monday or Tuesday of each week.
I will keep my telephone and address information current at all times.
I will keep my child's immunization record up to date at all times.
Other
Parent Signature
Date
Witness Signature
Date
COVID-l9 PUBLIC HEALTH EMERGENCY SPECIAL PROGRAM ATTENDANCE ACKNOWLEDGMENT AND DISCLOSURE
FAMILY/CHILD VERSION: This should be initialed and signed by BOTH parents.
Please read and initial each statement below.
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.
Greetings Parents,
The following program policies are designed to ensure that all enrolled children receive a quality preschool education.
Attendance Policy
Regular attendance is important for your child to maintain steady progress and to enjoy the benefits of a high-quality early childhood experience. If your child is ill or unable to attend school, please send your child's teacher a note to report the absence. Excessive absences are unacceptable and your child's enrollment in the program may be jeopardized. This policy also includes extended vacations.
First Occurrence (3 absences): Teacher will verbally remind parents about the importance of daily attendance.Second Occurrence (5 absences): Teacher will meet with the parent/guardian to discuss the reason for absences and strategies to be utilized to avoid absences in the future.Third Occurrence (10 absences): Program director will confer with the parent regarding excessive absences and develop a plan of action to ensure daily school attendance.Fourth Occurrence (15 absences): Parent receives written notification that continued absences will result in child's removal from the class list.Fifth Occurrence (18 absences): In consultation with the program director, the child is placed back on the waiting list and the slot will be filled by the next child on the waitlist.
Thank you for adhering o the program policies. Our goal is to support children and families whenever possible and it is never our wish for a child to be dismissed from our program. We hope that these policies and procedures will provide a foundation for a strong program that will meet the needs of students, parents, and staff.
Director, Little Peoples Village
I have received and understand Little Peoples Village Attendance Policy PKC/Head Start
Parent Name
Parent Signature
Date
Director Name
Director Signature
Date
Document ID No.
Title: Policy to Reduce and Ultimately Eliminate Suspension and Expulsion of Children
Date Prepared:
Revision
Effective Date:
Policy:
This policy depicts LPVs methodology of reducing and eliminating the suspension and expulsion of children
Purpose:
The purpose of this policy is to identify positive behavior support guidelines and tools to be used by teaching and non-teaching staff at LPV; to raise awareness about suspension, expulsion and excessive disciplinary practices at the early childhood level to our families; to provide support through parent partnerships to help families who are experiencing challenging behaviors in the home by providing clear, age appropriate and consistent expectations and consequences to address challenging behaviors in a fair and equitable manner.
Scope:
This procedure applies to all teaching and non-teaching staff; the guidelines are mandatory and must be practiced diligently prior to the advancement of the next tier level of addressing disciplinary action.
Authorities/Responsibilities:
It is the responsibilities of the Executive Director, Director, Assistant Director to ensure teachers are empowered to implement all positive behavior tools as outlined in this policy and to provide teachers and support staff with adequate training and resources to address challenging behaviors in the classroom. At the completion of training, all staff and support staff will be responsible to ensure are implemented.
Procedures:
Teachers will implement the following strategies on a consistent basis to reduce challenging behaviors exhibited by children. Teachers will consistently document the use of these strategies and the results, whether positive or negative, daily.
Positive Behavior Support Strategies All Teaching and Non-Teaching Staff will implement the following procedures to curtail existing challenging behaviors exhibited by children in their care
Visual Supports
Design and post at children's eye level, a visual schedule complete with both pictures and words
The visual schedule is utilized consistently and adapted based on student needs
Expectations
Design with children, and post 3-5 classroom rules with pictures
Classroom rules are positive, specific and descriptive
Classroom procedures, responsibilities, rules are explicitly taught and reviewed frequently
Praise and Positive Reinforcement
Behavior specific praise is used to reinforce appropriate behaviors
Praise is used when catching students make positive choices
Using a calm, low, neutral tone voice to provide short simple directions when redirecting inappropriate behaviors
A ratio of 4:1 (praise to behavior correction statements) is used
A combination of verbal and physical praise is used (e.g., thumbs up, high five, stickers, kiss your brain, tokens, etc.)
Transition Procedures
A warning of "one more minute" or something similar is used to signal a transition
A transition signal is used (ring bell, blow whistle, turn off lights, play a transitional song)
Provide personal face-to-face warning to children who have difficulty with transitions
Provide more than one reminder when possible (e.g., 5 minutes until... 2 minutes until...)
Expected behaviors are clearly stated at transition times (e.g., hands at side, quite mouths)
Provide Alternative Choices, if possible
Provide an alternative activity that will avoid disrupting others if child is unable or unwilling to participate in current activity
Permit child to sit in cozy corner to read; play with a puzzle, have writing center open and stocked with crayons, markers and paper to encourage writing or drawing; permit calming music to be played and/or any other calming activity
When child is redirected to the alternate activity, the child should be quietly praised and never punished
Allow Opportunities for helping
Develop and implement a job chart
Allow children to engage in jobs (e.g., wipe tables, organize toys, books, cubbies)
Introduce Scripted Stories
Implement scripted stories such as "Tucker the Turtle," and "Super Friend." Other suggested scripted stories can be located on the Center on the Social and Emotional Foundations for Early Learning (http://csefel.vanderbilt.edu/index.html )
Teach children how to identify their feelings (e.g., use visual feeling charts, games, puppets, etc.)
Practical Teacher Engagement with an aggressive or aggravated child
Teachers can sometimes help diminish and/or eliminate student's aggressive behaviors by implementing strategies listed above; as well as practicing the following step-by-step engagement procedures:
When a child exhibits aggressive behaviors that jeopardizes the physical safety of self, classmates and others, avoid physically handling or restraining the child. Only restrain a child if the child is a danger to himself and others
Never grab a child by the arms; if you need to remove a child from a dangerous situation, go behind him/her, and lift the child from under the armpits
Quickly relocate the child to a safe spot (writing center, cozy corner, etc.)
Give the child time to calm down; do not continue talking (badgering) the child during the calm down period. Let the child process and encourage child to take deep breaths.
During conversations with the child, keep your voice calm and in a low tone
Ask child what else can he/she do to calm down besides deep breathing. Listen and accommodate child with responses, if possible: count fingers, draw, exercise, etc.
Eliminate calling out a child's name repeatedly- It is bad press! It causes the child to be put on the spot; it encourages bad behavior and it gives other children a name to blame.
Once child has calmed down, revisit the discussion about what made the child upset and revisit alternative behaviors
If the above strategies fail to change inappropriate behaviors, advancement to the next level on the progressive disciplinary procedure will be implemented for the individual child.
Design specific strategies for individual children
Revisit the Tucker the Turtle Story daily and continue to have children practice the steps
Tailor the Tucker story to fit individual students (e.g., include child's name, specific behaviors exhibited by child, add child's picture, etc.)
Encourage and praise child for expressing his/her feelings
Remind him/her of strategies to regulate him/herself (e.g., counting down from 10, taking a walk, deep breathing, etc.)
If the use of these additional intervention strategies fails to improve challenging behaviors exhibited by children, advancement to the next level on the progressive disciplinary procedure will incur.
If the use of these additional intervention strategies fails to improve challenging behaviors exhibited by children, advancement to the next level on the progressive disciplinary procedure will incur.
Required Parent Conferences
Center director initiates a parent conference to discuss individual children's challenging behaviors
Director and parent collaborate to develop and implement an individualized plan to address learning goals and behaviors. Discussion will be held with child to demonstrate the partnership between the school and home. Director and parent will set a time-line and meet again to discuss child's progress
If behaviors continue, director will initiate another parent conference to revisit strategies implemented both at home and at school
If behaviors continue to persist, director initiates another parent conference to discuss agency intervention
Implement Agency Intervention
Director discusses with parents about agency intervention, if needed. Parents are provided contact information on our Mental Health Consultant and an appointment will be arranged.
Parent meets with the Mental Health Consultant and if agency intervention is required, parent provides permission for child to be screened
Director suggests parents take a dual-action approach in obtaining services; parent must contact outside services recommended by center as well as contact their individual insurance companies to get recommendations of other agencies to contact. Director provides recommended locations including:
Birth to 3 years of age:
Community Behavioral Health (http://dbhids.org/) - 215-413-3100
City of Philadelphia Early Intervention Intake (Childlink) - 215-685-4646
3 to 5 years of age:
Child Crisis Treatment Center - 215-496-0707
Etwyn - 215-895-5500
Child Guidance Center- 267-713-4100
Community Council - 215-473-7033
Philadelphia Mental Health Clinic- 215-735-9379
NorthEast Treatment Center - 215-451-7000
Preschool Family Intervention Center through the Community Council - 215-473-7033
Director provides 15 days for parent to contact suggested providers and insurance company to schedule an appointment for child evaluation.
Call and Retrieve Procedure: During the 15-day period, the parent will be called if the child continues to injure him or herself; another child, a teacher or a staff person, and the student must be picked up within one hour. If the parent does not pick up the child within one hour, the child will not be able to return the next day.
If the parent refuses to seek additional help within the required timeline of 15 days, and if the child continues to injure him or herself; another child, a teacher or a staff person, the parent will be called to retrieve the child for the day. The parent will be given one hour to pick up the child. If the parent fails to pick up the child within one hour, the parent will have to keep the child home the following day.
If parent fails to pick up their child within one hour after two consecutive occasions, the parent will incur a late fee of $25.00 per hour until the child is picked up.
If the child continues to be incontrollable, and causes injury to him or herself, peers, teachers or staff persons; and/or child attempts to destroy center property, the parent will be called to retrieve the child, within one hour; and if behaviors persist for several days in a row, the parent will be required to keep the child home for a cool-down period of 1-3 days.
Parents must provide an appointment card to demonstrate good faith in scheduling the appointment.
The call and pick up procedure as described above will continue during scheduling of appointment and evaluation.
If parents fail to complete an evaluation within the second 15-day extension, the parent will be informed their child will be placed back on the waiting list for 30 days until an evaluation has been completed. As an alternative, the parent can provide their own wrap-around service for their child.
This extension will be the final opportunity for the parent to get child evaluated. During this holding period, parent is not responsible to make their copayments
Failure of the parent to complete an evaluation within the timeframe will result in the child being placed back on the waiting list until such services have been provided, and the childcare slot will be opened to other parents seeking childcare.
During the holding period, the call and retrieval of child for incidences of aggression that hurts child, teacher, peers or staff will continue until evaluation.
This extension will be the final opportunity for the parent to get child evaluated. During this holding period, parent is not responsible to make their copayments. Failure of the parent to complete an evaluation within the timeframe will result in the child being placed back on the waiting list until child have been evaluated and/or center support has been provided by the parent.
Extreme Circumstances:
If a child has demonstrated extreme aggression towards him or herself; teachers, staff and/or other children on a consistent basis, the above process will be eliminated, and the parent will be required to seek intervention on their own (resources provided in this policy) immediately prior to the child being able to return to the center. The parent must demonstrate good faith by submitting an intake appointment card with an upcoming date for the child to return and provide follow-up documentation indicating that the parent and child completed their intake services will be rendered to help support the child's aggressive behavior at the center and towards others. If the parent fails to keep the appointment, the child will be placed back on the waiting list until the services has been provided.
Any child that has been extremely aggressive and has broken any of the classrooms items, the parent will be responsible for replacement and/or purchase of the broken item.
Director's Name and Title
Director, Little Peoples Village II
I have received and understand Little Peoples Village Suspension and Expulsion Policy
Staff Name
Staff Signature
Date
Director Name
Director Signature
Date
Little People’s Village
CHILD and FAMILY INFORMATION FORM
The information and documentation you provide will assist the Office of Early Childhood Education in determining your eligibility for The School District of Philadelphia's preschool program, You are obligated to provide accurate and complete information. Deliberate misrepresentation of your information may subject you to prosecution under applicable Federal and/or State laws. PLEASE PRINT CLEARLY and use BLUE or BLACK INK.
Section 1: LOCATIONS
CHOOSE THE LOCATION(S) WHERE YOU WOULD LIKE YOUR CHILD TO ATTEND: Review the 2017-2018 School-Based Preschool Locations on pages 5-6. Select 1, 2 or 3 locations in preference order. If your child is accepted to preschool, the locations you select and the availability of funding in those locations will determine which location is chosen for your child, BEFORE-SCHOOL, AFTER-SCHOOL and TRANSPORTATION ARE NOT PROVIDED. You must be able to bring your child to school and pick up your child from school on time.
Name of your 1st Location Choice:
Name of your 2nd Location Choice:
Name of your 3rd Location Choice:
First Name
Last Name
Date of Birth:
Address
Apt./Unit No
Zip Code
Race/Ethnicity Select all that applies
Primary language
Other language(s);
English is spoken in the home
Primary Parent/Guardian:
Date of Birth:
Parent has an active custody arrangement for this child
Child lives with (select all that applies)
Mother Complete if child does not live with his/her mother
Name:
Address:
Contact phone:
Does the child's mother provide financial support to the child?
Father Complete if child does not live with his/her father
Name:
Address:
Contact phone:
Does the child's father provide financial support to the child?
Little People’s Village
#1 CHILD and FAMILY INFORMATION FORM
Child's Name:
Date of Birth:
Section 2: CHILD. continued
If 'Yes', list all disabilities:
Child has an IEP (Individualized Education Plan), an IFSP (Individualized Family Service Plan) and/or an ER (Evaluation Report) and is receiving Early Intervention services from ChildLink, ELWYN or ELWYN Seeds.
If 'Yes', indicate which Early Intervention services your child is receiving (select alt that applies):
Child wears diapers and/or pull-ups.
If 'Yes', when (select all that applies):
If other, please specify
'If 'Yes', will child be able to use the toilet with minimal adult assistance while in preschool?
Child is/was in preschool or daycare
If yes, please specify name
If 'Yes', is your child still attending preschool/daycare?
If no, please specify last date of attendance:
I/We have a medically fragile child (chronic illness. terminal illness, etc )
If 'Yes', name of child:
Child's mother and/or father is currently incarcerated
Child's mother and/or father is deceased.
There have been important changes in my child's life during the last 12 Months
If 'Yes', please explain:
Child was referred to a preschool program from a mental health provider.
Doctor/Clinic/Office Name:
Address:
City:
State:
Zip Code:
Phone:
Doctor/Clinic/Office Name:
Address:
City:
State:
Zip Code:
Phone:
How did you hear about The School District of Philadelphia's preschool program? (select all that applies):
Please share any additional information about your child that you would like us to know.:
#1 CHILD and FAMILY INFORMATION FORM
Child's Name:
Date of Birth:
Section 3: PRIMARY PARENT
The adult who is primarily responsible for the care and well-being of the child.
First Name
Last Name
Date of Birth:
Primary language
Primary Parent/Guardian:
Home Address:
Apt./Unit #:
City:
State:
ZIP Code:
Home Phone:
Cell Phone:
Email Address:
Alternate Phone:
Alternate Phone # belongs to:
Best way to reach you during the day: Select alt that applies
If other please specify:
Marital Status Select one
If other please specify:
Relationship to Child Select one
If other please specify:
If other please specify:
Does your family receive welfare benefits?
If 'Yes', your record/case # (NOT the on your EBT card):
If 'Yes', which benefits are received?
Does your family receive WIC?
Education (Select highest Diploma/Degree earned or highest Grade Level completed)
If other please specify:
Employment, School, Job Training (Select all that applies)
Employer Information Complete if you are Employed/Self-Employed
Employer/Business/Company Name:
Address:
City:
State:
Zip Code:
Phone:
What type of work do you do?
If other please specify:
School/Job Training information Complete if you attend High School, College or a Job Training program
School/Job Training Name:
Address:
City:
State:
Zip Code:
Phone:
What are you studying?
Do you have a disability or disabilities?
If 'Yes', please list your disabilities:
Do you have health insurance?
If 'Yes', name of health insurance provider:
Housing Information (Select your current situation)
Since what date have you been in your current housing situation?
During the past 12 months, l/we have moved from temporary to permanent housing.
During the past 2 years, t/we have moved into a new house
Do you have a mental health concern?
Do you have a social concern (English language learner, eating disorder, custody issues. etc.)?
If 'Yes', please list your concerns:
Please share any additional information about the Primary Parent that you would like us to know:
Section 4: SECONDARY PARENT
An adult who shares in the care of the child.
First Name
Last Name
Date of Birth:
Primary language
Primary Parent/Guardian:
Home Address:
Apt./Unit #:
City:
State:
ZIP Code:
Home Phone:
Cell Phone:
Email Address:
Alternate Phone:
Alternate Phone # belongs to:
Best way to reach you during the day: Select alt that applies
If other please specify:
Marital Status Select one
If other please specify:
Relationship to Child Select one
If other please specify:
If other please specify:
Education (Select highest Diploma/Degree earned or highest Grade Level completed)
If other please specify:
Employment, School, Job Training (Select all that applies)
Employer Information Complete if you are Employed/Self-Employed
Employer/Business/Company Name:
Address:
City:
State:
Zip Code:
Phone:
What type of work do you do?
If other please specify:
School/Job Training information Complete if you attend High School, College or a Job Training program
School/Job Training Name:
Address:
City:
State:
Zip Code:
Phone:
What are you studying?
Do you have a disability or disabilities?
If 'Yes', please list your disabilities:
Do you have health insurance?
If 'Yes', name of health insurance provider:
Do you have a mental health concern?
Do you have a social concern (English language learner, eating disorder, custody issues. etc.)?
If 'Yes', please list your concerns:
Please share any additional information about the Secondary Parent that you would like us to know.
Please share any other additional information that you would like us to know.
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
FIRST and LAST NAME
DATE of BIRTH
RELATIONSHIP to PRIMARY PARENTSelf, Husband. Wife. Daughter. Son, Mother. Father Sister, Brother, Companion, Partner, Friend. etc.
1
2
3
4
5
6
7
8
Section 6: FAMILY INCOME
Indicate how you financially provide for your family. Select each source of income that the Primary Parent, Secondary Parent and all children receive.
If other please specify:
Section 7: SIGNATURES
Read the following and sign where indicated.
l/We have completed all sections on my/our Child and Family Information Form and certify the information is correct. I/We understand that if any of my/our information is false, my/our participation in the preschool program may be terminated and l/we may be subject to legal action. l/We have attached a copy of my/our child's proof of date of birth, verification of my/our Philadelphia, PA address and copies of all income and monthly benefits that I/we and my/our children receive. l/We understand that this information is being given so that my/our eligibility can be determined for The School District of Philadelphia's preschool program. I/We understand that officials from The School District of Philadelphia, the Department of Health and Human Services and the Commonwealth of Pennsylvania will have access to and may verify the information and supporting documentation submitted with my/our Child and Family Information Form. l/We further understand that, if necessary, additional documents may be requested and I/we will comply with this request. l/We understand that my/our child's complete Preschool Application is confidential and 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.
Signature of Primary Parent:
Date:
Signature of Secondary Parent:
Date:
#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:
1. Name of restricted food:
2. Name of restricted food:
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:
Name of Location:
Signature of Early Childhood Staff:
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:
1. Diagnosis or medical condition:
Medication name, dose and times
2. Diagnosis or medical condition:
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:
Name of Location:
Signature of Early Childhood Staff:
Date:
THE SCHOOL DISTRICT OF PHILADELPHIA OFFICE OF EARLY CHILDHOOD EDUCATION 110 N BROAD STREET SUTIT 170 PHILADELPHIA PENNSYLVANIA 19130
Part I: Place a check mark in the No or Yes Column next to each item. For all Yes responses, please explain in the Comments column
DOES YOUR CHILD
YES
NO
COMMENTS
Wear glasses
Have a lazy eye, crossed eyes, wandering eyes, other eye conditions
Have a history of ear infections, tubes in ears, hearing loss, wear hearing aid
Have excessive colds, sore throats, coughing episodes, or snores loudly
Have a history of asthma or bronchitis
Have a heart murmur, a resolved heart murmur, rheumatic fever or other heart conditions
Have a history of anemia, sickle cell disease, elevated lead level or other blood condition such as G6PD, hemophilia, etc.
Have or had an umbilical or inguinal hernia
Have a feeding tube
Have trouble urinating, urinary tract infection or kidney disease
Wear diapers/pull-ups
Have diabetes (If yes, please indicate Type I or Type II diabetes)
Have rashes, eczema, hives, boils
Have neuropathy, muscle tics, spina bifida, muscular dystrophy, cerebral palsy
Wear leg braces
Use a cane, walker or wheelchair
Have (or had) polio, chicken pox, measles, mumps, scarlet fever, whooping cough
Have car sickness
Have allergies due to medication or food
Have allergies due to seasonal changes, animals, or other
Take medication daily or on an “As Needed” basis
Please share with us any health concerns you have for your child:
Little People’s Village
#4 POLICIES and CONSENT for EMERGENCY MEDICAL CARE and SCREENINGS FORM
This form will be taken with your child when emergency medical care is needed.
Child's Name:
Date of Birth:
EMERGENCY MEDICAL CARE POLICIES
Parents, you are responsible for making arrangements for alternate care for your child if s/he is ill, needs close supervision or has a contagious condition and cannot attend preschool. You are also responsible for transportation if your child has an illness or minor injury while at preschool, not sufficiently severe to warrant emergency medical transportation.
In the event your child becomes seriously ill or injured and requires immediate medical attention, s/he will be accompanied by staff and taken to the nearest hospital emergency room in an emergency medical vehicle. We will attempt to notify you at once. Under the Medical Services/Minor Act, immediate emergency treatment will be initiated at the hospital. However, it is essential that your child's teacher and the hospital is able to locate you as soon as possible, to give either written or monitored verbal permission for comprehensive treatment. Please be sure to keep your child's teacher informed about how to reach you at all times.
You are responsible for the costs of medical treatment if your child is injured. Please contact Early Childhood Health Services if your child needs medical insurance.
Doctor's note is required before your child can return to preschool if s/he has any of the following: an emergency room visit, certain cases of illness (contagious, serious, requires a long absence, surgery, etc.), or certain cases of injury (needing doctor's care, cast or brace. special activities, etc.). If you have any doubt, please obtain a doctor’s note whenever your child goes for medical care.
CONSENT for EMERGENCY MEDICAL CARE and PREVENTIVE SCREENINGS
My signature below indicates that I understand the Emergency Medical Care Policies and give consent for:
The administration of minor first aid to my child by preschool classroom staff.
The emergency medical and/or dental care which may be necessary to preserve the life of my child or to prevent impairment of his/her health in the event that time does not permit obtaining my personal consent for such care I understand that I will be contacted as soon as possible, and will assume responsibility for giving permission for on-going care.
My child to participate in the Office of Early Childhood Education's screening program which may include, but is not limited to: developmental screening, behavioral screening, vision screening, hearing screening and dental screening. I understand that as part of the preventative health program, children participating in preschool programs of The School District of Philadelphia receive screenings during the school year.
lf you have any questions about the above information, please speak with a representative from Early Childhood Health Services.
Signature of Parent/Guardian:
Date:
Name of Location:
Signature of Early Childhood Staff:
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:
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.
Completing and submitting a Preschool Application does not guarantee that my/our child will be accepted to a preschool program.
Before my/our child's first day in preschool:
I/We will attend an orientation meeting and an individual conference with my/our child's teacher and will receive a Parent Handbook.
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.
I/We may be required to re-verify my/our Philadelphia, PA address, family income and/or monthly benefits.
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:
S/He will attend every school day, his/her health permitting.
S/He will be escorted to and from school by an individual who is at least eighteen (18) years old.
S/He will be able to use the toilet with minimal adult assistance
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.
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.
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:
2022-2023 PA Pre-K Counts Enrollment Form
(This information is confidential to the PA Pre-K Counts program)
Date Form Completed:
Last Name (Child):
First Name (Child):
Middle Initial:
Street Address:
County:
City:
State:
Zip Code:
School District of Residence:
Home Phone:
Work Phone:
Email Address:
Child’s Date of Birth:
(Please specify):
Name of Parent or Guardian completing this application:
Relationship to Child:
(please specify)
(Select):
(please specify)
List Household Members below for determination of family size (required):
Relationship to Child
Age
1
2
3
4
5
6
7
Per PKC Statute, Regulations, and Guidance, the following members of the household are included in family size:
Parent of the child (biological or adoptive mother or father, stepmother or stepfather, caretaker or spouse)
A biological, adoptive, unrelated or foster child or stepchild of the parent or caretaker who is under 18 years of age and not emancipated.
A child who is 18 years of age or older but under 22 years of age who is enrolled in high school, a general educational development program, or a post-secondary program leading to a degree, diploma or certificate and who is wholly or partially dependent on the income of the parent or caretaker or spouse of the parent or caretaker.
Others supported by the income of the parent(s) or guardian(s) of the child enrolling or participating in the program. If counted toward family size, any applicable income of these persons must also be counted for eligibility purposes.
Note: A family size value of one (1) with an income of $0 is entered when a foster child is applying for Pennsylvania Pre-K Counts.
DETERMINED FAMILY SIZE
Employment Status of parent/guardian:
(please specify)
Employment Status of 2nd parent/guardian (if applicable):
(please specify)
Household Income Sources (Must check all that apply):
Other Child Eligibility Risk Factor Criterion (Must check all that apply):
To the best of my knowledge, the information provided in this application and the associated income documentation is accurate. I understand that I may be asked to verify or substantiate information provided.
Parent/Guardian (Signature):
Date:
Parent/Guardian Name (Print Name):
Completed by your child's dentist return this form with your child's application
THE SCHOOL DISTRICT OF PHILADELPHIA
REPORT OF PRIVATE DENTAL EXAMINATION
Name of School:
Student ID:
Date issued:
Name of Student:
Date of Birth:
Room/Section/Book:
Grade:
TO THE DENTIST
Pennsylvania law requires that students attending school in the Commonwealth receive periodic dental examinations at stated intervals (upon original entry, while in third grade, and while In seventh grade).
These examinations are required for school attendance. Payment for these examinations is the responsibility of the parent/guardian. If the student/family does not have health insurance the school nurse will help the family apply for health insurance. Please attach a copy of the student's dental examination or record the data below.
Thank you for your cooperation.
UNDER TREATMENT/WORK BEGUN
Date Work Begun:
Scheduled Follow-up Appointment:
Date of Dental Examination:
Date of Cleaning:
Date of Fluoride Treatment:
Name of Dentist:
Telephone:
Signature of Dentist:
Date Signed:
Address:
Fax Number:
COMPLETION OF WORK/NO TREATMENT NECESSARY
Expected Completion Date:
Comments/Follow-up Treatment/Special Instructions to School:
