JUBILEE HERITAGE DAYCARE REGISTRATION FORM

Site: _____________________ Group:_____________________ Days attending:________________

Family name: __________________________ Child's Name:__________________________ Gender:___M___F

D.O.B: _________________________________ Phone number:________________________

Email address:_________________________________________________________________

Address:_______________________________________________________________________

Start date:____________________________ End date:______________________________

ALLERGIES : _____________________________________________________________________DOCTOR: __________________________ ADDRESS:________________________________

PHONE : __________________________ HEALTH CARD NUMBER: _______________optional

Mother: ___________________________ Employer: __________________________

Work phone: __________________________

Father: ____________________________ Employer: __________________________

Work phone: _________________________

Names of persons authorized to take the child in or out of the daycare. They may also be called in the event of an emergency if parent cannot be contacted. PERSONS NOT AUTHORIZED WILL NOT BE PERMITTED TO ENTER THE BUILDING.

Name:_____________________________ Relation:_______________________________

Address:____________________________ Phone:________________________________

Name:______________________________ Relation:_______________________________

Address:____________________________ Phone:_________________________________

Name:______________________________ Relation:_______________________________

Address:____________________________ Phone:_________________________________

For office use only: Copies: Emergency bag ( ) ( ) Main office ( )

subsidy ( ) Full fee ( ) Centre office ( ) clipboard ( )

Family and Social History

Marital status: __________________________________________________________________

The child is in legal custody of: _____________________________________________________

Siblings and ages: ________________________________ __________________

________________________________ __________________

________________________________ __________________

________________________________ __________________

Has the child been cared for other than parents? (daycare, family etc.) ________________________________________________________________________________

Language and Cultural information: __________________________________________________________________________________________________

Personal

How does your child react to sounds? (over-react or lack of response) __________________________________________________________________________________________________

Daily routine______________________________________________________________________________________

Does your child sleep through the night? ( ) yes ( ) no

What is his/her normal sleep pattern through the day? ________________________________________________________________________________

Does your child have any bowel or bladder irregularities? ( ) yes ( ) no

Is your child toilet trained? ( ) yes ( ) no

Word your child uses for toilet? ________________________________________________________________________________

Describe past and present fears of your child. ____________________________________________________________________________________________________________________________________________________________________________________________________

How does your child relate to new situations? ____________________________________________________________________________________________________________________________________________________________________________________________________

Anything else that you could communicate to us about your child? ____________________________________________________________________________________________________________________________________________________________________________________________________Infant Care

What is the best way to soothe your child? ____________________________________________________________________________________________________________________________________________________________________________________________________Are you still breastfeeding your child? Yes ( ) No ( )If yes, would your child also feed from a bottle? Yes ( ) No ( )Do you add any solids to your infant’s formula and how much? ____________________________________________________________________________________________________________________________________________________________________________________________________Is your infant on any other solids? ____________________________________________________________________________________________________________________________________________________________________________________________________Do you have any objections to an extra feeding if demanded by your child? Yes ( ) No ( )

Infant Questionnaire:Soother: So they walk around with it?______________________________________________________________

Bottle: Do you warm it or give it cold?______________________________________________________________

How often are they given a bottle?________________________________________________________________

Do they have a special blanket or toy?____________________________________________________________

How do you put them to sleep?___________________________________________________________________

Do they sleep in a crib?___________________________________________________________________________

Do they sleep with you?___________________________________________________________________________

Can they go in a swing?__________________________________________________________________________

Are they trying to walk? Holding on to furniture?____________________________________________________

How long do they usually sleep?___________________________________________________________________

What times do they usually go for a nap?__________________________________________________________

Do they like to sleep on their backs or their side?___________________________________________________

Do they like to be rocked?________________________________________________________________________

How often do you burp him or her during a bottle?_________________________________________________

School age Child Care

Does your child have any difficulties in speaking or comprehending? __________________________________________________________________________________________________

How does your child feel about school? ___________________________________________________________

Previous school concerns _________________________________________________________________________

Current involvement in extra-curricular activities (Brownies, Scouts, swimming, hockey etc) __________________________________________________________________________________________________

What are your child's favourite activities/interests? ________________________________________

Does the child enjoy/prefer playing alone? _______________________________________________

What makes the child angry or upset? ____________________________________________________

How does your child show these feelings? _________________________________________________

How would you suggest we handle your child when angry or upset? _______________________

Does your child have any fears? __________________________________________________________

Are there particular ways you think we might be able to help your child? ___________________

SCHOOL AGE CHILDREN

Child Care Needs

You child is enrolled in the school age program which is available before and after school. We also have available an extended program which runs on professional development days and on school holidays.

The summer program (July/August) may be offered at a site your child does not currently attend.

Please indicate your child care needs for the ________________________ school year.

________________ I require only before and or after school. I understand that if I would like care for my child on a school holiday or professional development day, I must book in advance with the daycare supervisor.

________________ I require before and after school and holidays and professional development days. I understand that this will reserve my child's spot for these days.

______________________________ _________________________Lead Date

______________________________ _________________________Parent Signature Date

All Children

Dear Families,

Your answers to the following questions will help us greatly in our efforts to develop and incorporate your child's home and community experiences in our early childhood setting.

Name some interests and activities that have particular meaning to your child (such as reading, skipping, etc.)? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name some interests and activities or hobbies that your family participates in (such as, music, hiking etc.)? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What special days do you celebrate (such as religious holidays, birthdays etc.)? How do you celebrate them? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What kinds of activities or events do you do in the community with your family (such as going to the park, Dragon Boat Festival etc.)? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What type of activities would you like to participate in at our agency ( such as cooking activities, becoming a board member) ? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Health HistoryImmunization Dates: (photocopy yellow immunization card and attach)Illnesses (approximate dates)Chicken pox ______________________________ Scarlet Fever ____________________________________Red Measles ______________________________ Rheumatic Fever ________________________________Mumps ___________________________________ Pneumonia ______________________________________Whooping cough _________________________ Bronchitis ________________________________________Rubella ___________________________________ Others ___________________________________________

Hospitalization (nature and dates of accidents): __________________________________________________________________________________________________

Is your child still concerned about the above? __________________________________________________________________________________________________

Do you feel your child has any “special needs”? ( Epilepsy , fainting, diabetes, asthma, allergies)__________________________________________________________________________________________________

Does your child have any limitations/restrictions? (Speech, hearing, vision, orthopedic, cardiac)__________________________________________________________________________________________________

Is your child on regular medication?__________________________________________________________________________________________________

Parent’s evaluation of child's health:__________________________________________________________________________________________________

Other Information:

Anything else you can tell us about your child and your family? (can be continued on back of page) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How did you hear about our service? ____________________________________________________________________________________________________________________________________________________________________________________________________

Jubilee Heritage Family Resources Personal Information Privacy PolicyConsent formI understand that Jubilee Heritage Family Resources/Les Resources familiales Jubilee Heritagehas a personal Information Policy in accordance with the requirements of the Personal Information Protection and Electronic Documents Act (PIPEDA)

By signing below, I am consenting to the collection, use and disclosure of my personal information ( such as my home telephone number and address and any emergency contact telephone numbers) in accordance with the purposes set out in the policy which include the following:

to maintain complete and accurate client files and to comply with all requirements and legislation of the funding and licensing bodies. to provide services and to communicate effectively with our clients to bill for services and collect unpaid accounts to permit a potential transfer of this agency to carry out due diligence to confirm factual and other information about the organization to comply with all lawful requests for government agencies to allow the Board of Directors to carry on board issues

I understand that:

My personal information will not be used or disclosed for purposes other than those for which it was collected, except with my consent, or except where the use of disclosure is required by law I have the right to view my personal information and have it amended , if inaccurate or incomplete A copy of the policy will be provided upon request

_____________________________ _______________________________Signature Date

_____________________________Printed

Consent FormI hereby authorize the Sudbury Jubilee Daycare to:

videotape ( ) record ( ) photograph ( )

for the purpose of:

staff development ( ) public presentation ( ) publicity (media) ( ) playroom use ( )

involving my child(ren), _______________________________________________________ given name and surname may be used ( )given name only may be used ( )I am aware that whenever possible, I will be notified prior to such occasions arising.

__________________________ _____________________________ ___________________ Parent Signature Staff signature Date

Bike Helmet AgreementThis is to verify that I understand that my child will be in need of a bike helmet to use the daycare trikes. If I am financially unable to supply a helmet, my child may use one supplied by the daycare after it has been fitted by me. I also understand that if my child does not have a helmet they will be unable to use the daycare trikes.( ) Agreement that a bike safety helmet will be brought in daily for use of the daycare trikes( ) Agreement that parent will buy a second helmet for daycare use only( ) Agreement that child will use a daycare helmet after it has been fitted by me

_______________________ ______________________ __________________________ Parent signature Staff signature Date

Permission of OutingsThis is to certify that I hereby give permission for my child to be included in all outings or excursions organized by Jubilee Heritage Daycare. I understand that I will be given prior notice of all major outings, but that some short walks etc, will not be announced beforehand.

______________________ _______________________ _________________________Parent Signature Staff Signature Date

Parental Consent for Emergency Medical Care and Transportation

Name of child:______________________________________

If at any time, due to such circumstances as an injury or sudden illness, medical treatment is necessary, I authorize the child care staff to take whatever emergency measures they deem necessary for the protection of my child while in their care.

I understand that this may involve calling a physician, interpreting and carrying out his or her instructions, and transporting my child to the hospital or physician's office, including the possible use of an ambulance.

I understand that this may be done prior to contacting me and that any expense incurred for such treatment, including ambulance fees, is my responsibility.

______________________________________ ____________________________________Parent Signature Date

______________________________________ ____________________________________Daycare Supervisor Signature Date

Other TransportationIf at any time, a child who is on an outing and cannot return to daycare with the group, I understand and authorize my child to be transported by taxi cab back to daycare. In this case, the supervisor or designate will meet the group at the outing site and escort the child back in the taxi back to the centre.

_______________________________________ ___________________________________Parent signature Date

_______________________________________ ___________________________________Daycare Supervisor Signature Date

Statement of Acknowledgment Audio/Video System

I, ___________________________________________ , acknowledge that I have been informed of an audio/ video system that is recording events in the playrooms and infant sleep room in the daycare at all sites. I am also aware that signs are posted on the doors of the playrooms that indicate the system is in place.__________________________________ _____________________________ __________________Parent Signature Staff Signature Date

Sun Screen AuthorizationI authorize the administration of sun screen purchased by me to ________________________(name of child) by the Jubilee Heritage Daycare Staff to be applied prior to going outside and according to the bottle instructions.Start date:______________________________________Have you observed any reactions to sun screen? ( ) yes ( ) No

____________________________ ______________________________ ____________________Parent Signature Staff Signature Date

Policy for the Release of Children

It is a legal responsibility that as professional educators we ensure that the person to whom we are releasing a child is capable of taking care of the child. The following procedure addresses preventative measures and failing these measures describes action to take should a staff at Jubilee Daycare suspect the person is not capable of caring for the child.

The parent agreement contract and parent handbook will describe the “ Release of Children” policy and expectations of parents, guardians and approved alternatives.

At point of enrollment/registration parents will sign off o that they have discussed this matter and understand that in the event that any authorized person who came to pick up a child due to intoxication or other circumstance, the staff are instructed to arrange for alternate authorized person or if unsuccessful to contact the police and the Children’s Aid Society.

It is policy that any person who is intoxicated with drugs or alcohol will not be allowed on premises.

Procedure for StaffIf the staff person deems the authorized person picking up the child to be incapable of caring for the child he/she will:

Inform the parent that according to policy he/she will contact an alternative person to pick up the child.

If the parent does not wish to wait for an alternative person, then the staff will follow policy by calling the police and then report to the Children's Aid Society.Date: ___________________________ Signature of Parent ____________________________________

Signature of Day Care Supervisor ___________________________________

Times of Care

All families who use our daycare services make an agreement with us regarding the times their children will be in care of our staff. This is done so that all children can get the safest and most secure care that we can provide. We use these prearranged agreements to plan staffing most efficiently.

Please co-operate in keeping with these arranged times. If there are any changes, with sufficient lead time, we may be able to accommodate your needs.

Daycare is needed _________________________ From _______ a.m. To _________ p.m.

________________________ _____________________________ ___________________Parent Signature Staff Signature Date

It is of great importance that the centre's staff be notified immediately of any change at all in the information given. Also, you are urged to feel free to discuss any matters concerning your child with the staff at any time.

_________________________ ____________________Parent Signature Date

We can only accommodate a minimum amount of children whose scheduled days rotate from week to week, or require only half a day of care.

If at any time your daycare needs change to rotating days or half days, you may be asked to find alternate care. We will do our best to assist you.

ONTARIO CHILD AND FAMILY SERVICES ACT (CFSA)

The Ontario Child And Family Services Act recognizes that each person has a responsibility for the welfare of children. It states clearly that members of the public, including professionals who work with children have an obligation to report promptly, to a Children's Aid Society (CAS); if they suspect that a child is or may be in need of protection. CFSA s.72(1) A child in need of protection is a child that has experienced physical, sexual and emotional abuse, neglect and risk of harm.

As professionals in the field of Early Childhood Education, we are obligated to contact the CAS if we have reason to believe that:

The child has suffered physical harm, inflicted by the person having charge of the child or caused by or resulting from that person's

a)Failure to adequately care for, provide for, supervise or protect the child orb)Pattern of neglect in caring for, providing for, supervising or protecting the child

There is a risk that the child is likely to suffer physical harm inflicted by the person having charge of the child or caused by or resulting from that person's

a) Failure to adequately care foe for, provide for, supervise or protect the child, orb) Pattern of neglect in caring for, providing for supervising or protecting the child.

The child has been sexually molested or sexually exploited, by the person having charge of the child or by another person where the person having charge of the child knows or should know of the possibility of sexual molestation or sexual exploitation and fails to protect the child.

There is a risk that the child is likely to be sexually molested or sexually exploited as described in paragraph 3.

The child requires medical treatment to cure, prevent or alleviated physical harm or suffering and the child's parent of the person having charge of the child does not provide, or refuses or is unavailable or unable to consent to, the treatment

The child has suffered emotional harm, demonstrated by serious,a) Anxietyb) Depressionc) Withdrawald) Self-destructive or aggressive behaviour, ore) Delayed developmentand there is reasonable grounds to believe that emotional harm suffered by the child results from the actions, failure to act or pattern of neglect on the part of the child's parent or the person having charge of the child.

The child has suffered emotional harm of the kind described in sub paragraph I, ii, iii, iv, v of paragraph 6 and the child's parent or the person having charge of the child does not provide, or refuses or is unavailable or unable to consent to, services of treatment to remedy or alleviate the harm.

Professionals who work with children have a responsibility to report their suspicions, therefore failure to report is an offense in accordance to CFSA s. 72 (4), (6.2)

Any professional who fails to report a suspicion that a child is or may be in need of protection duties, is liable on conviction to a fine of up to $ 1000. The professional's duty to report overrides the provisions of any other provincial statute, specifically, those provisions that would otherwise prohibit disclosure by the professional. CFSAs 72 (7), (8).

If you have any questions or concerns about the Child and Family Services Act s. 72 (1) please feel free to speak to the Daycare Supervisor, or contact your local Children's Aid Society.

Thank you for your understanding of our professional obligation.

Please sign below indicating you have read and understand the above Child and Family Services Act.

__________________________________ _______________________________ ____________________Signature of parent(s) Daycare Supervisor Date

Jubilee Heritage Daycare

I HAVE READ, UNDERSTAND AND AGREE TO THE POLICIES OF JUBILEE HERITAGE DAYCARE AS OUTLINED IN THE PARENT HANDBOOK.

NAME: ______________________________________________________________________

SIGNATURE: _________________________________________________________________

DATE: _______________________________________________________________________

LEAD SIGNATURE: _____________________________________________________