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    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



































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






    PERIODIC REVIEW




    Agreement Form

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





    Type of Service:






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


    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)







    Periodic Review



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





    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.



    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: Yes/No 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

    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.
















    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)











    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.


    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.









    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.




    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






    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.

    Symptoms include,

    • • Fever of 100.4 degrees Fahrenheit or higher
    • • Dry cough
    • • Shortness of Breath
    • • Chills
    • • Loss of taste or smell
    • • Sore Throat
    • • Muscle aches

    While we understand that many of these symptoms can also be related to non-COVID-19 related issues we must proceed with an abundance of caution during this Public Health Emergency. These symptoms typically appear 2-7 days after being infected so please take them seriously. Your child will need to be symptom free without any medications for 72 hours before returning to the facility.

    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.











    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.

    Parent/Guardian Agreement

    To protect our children and staff, I agree to keep my child at home if he/she has any of the following symptoms:

    Watch for ANY of the following symptoms:

    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.