abide in the vine child care center · statements set forth by the board of directors of abide in...

Abide in the Vine Child Care Center

Application for Enrollment

Infants

[INFANT – REQUIRED FORMS]

Application for Enrollment INFANT – REQUIRED FORMS

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OUR VISION

To minister Christ’s love to the children and families of Owego and the surrounding areas by

providing a safe and loving environment where working parents may leave their children.

OUR PHILOSOPHY

We believe that all children are gifts from God. We recognize that the parents are the first and

best teachers of a child. We believe that the parents are entrusting to our care their most prized

blessings. We promise to tenderly guard and protect the children in our care.

We believe that God has given all children the ability to learn. We recognize that children

should be nurtured in the areas of physical, social, emotional and intellectual development. We

promise to provide experiences to encourage all areas of the child’s development.

We believe that God has given all children areas of special blessings. We recognize that each

child is unique in his or her gifts and abilities. We promise to search out and encourage each

child’s strengths.

We believe that God loves all his children. We recognize that all children need to feel love and

acceptance, encouragement and success. We promise to interact with your children with love,

joy, peace, patience, kindness, goodness, faithfulness, gentleness, and self-control.

We will start the day with a prayer, say grace at mealtimes, read Bible stories, sing Bible songs,

and say prayers at bedtime.

________________________________ _______________________ Parent’s Signature Date

RESERVING YOUR SPACE AT AVCCC: Please sign and return to AVCCC, 1277 Taylor Road, Owego, NY 13827

I wish to reserve an advance place for my child at AVCCC. I understand that

this requires the $25.00 one time registration fee plus one week tuition. I

further understand that this payment will reserve my child’s place for one

week only and that this fee is nonrefundable.

Signature: _______________________________________________ Date: ______________


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Abide in the Vine Child Care Center 1277 Taylor Rd., Owego, NY 13827

Registration Form

Child’s Name ____________________________________ Birthdate ______________________

Sex ________ Place of Birth _______________________ Nationality ____________________

Address ________________________________________ Telephone _____________________

Name of Mother or Guardian ____________________________ Age ____________________

Occupation _____________________________________ Work Phone ___________________

Name of Father or Guardian _____________________________ Age ____________________

Occupation _____________________________________ Work Phone ___________________

Marital Status of Parents _________________________________________________________

Custody-Visiting Arrangements ___________________________________________________

If child is adopted, list age at adoption ______________________________________________

Is child aware of adoption? _______________________________________________________

Emergency Information

Persons Authorized to Pick Up Your Child:

Name __________________________________________ Relationship _________________




Persons to be Notified in Case of Emergency:

Name ________________________________________________ Phone _________________

Name ________________________________________________ Phone _________________

Name ________________________________________________ Phone _________________

Child’s Physician ______________________________________________________________

Address _____________________________________________________________________

Emergency Hospital Preference ___________________________________________________

______________________ ______________________________

Date Parent Signature

For Staff Reference: Check those of file:

Immunization Record _________ Physical Examination _________ Birth Certificate _________


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Abide in the Vine Child Care Center Emergency Care

Child’s Full Name: ___________________________________________________________________

Child’s Home Address: _______________________________________________________________

Birthdate: ________________ Name of Person applying for Child: ____________________________

Please check one: □ Parent □ Caregiver □ Other □ Guardian

Mother’s (or Caregiver) Phone Numbers:

Home: ____________________ Work: ____________________ Cell: ____________________

Father’s Phone Numbers:

Home: ____________________ Work: ____________________ Cell: ____________________

Emergency Contact Persons: (people who you designated to pick up your child)

Relationship Contact Name Phone Number Cell Phone

1. _________________ _________________ _________________ _________________

2. _________________ _________________ _________________ _________________

3. _________________ _________________ _________________ _________________

4. _________________ _________________ _________________ _________________

Child’s Source of Medical Care/Primary Care Physician’s Name: _______________________________

Physician’s Phone Number ____________________________________________

Name of Medical Care Facility/Hospital: __________________________________________________

Does your child have any allergies? Yes? _________ No? ___________

If yes, please record allergies and any special needs:

In case of accident or injury, I authorize any and all emergency medical, dental, and for surgical care and

hospitalization advised by the physicians, surgeon, or hospital necessary for the proper health and well-

being of my child; including transportation for such services.

Yes ________________ No __________________

Please Sign _________________________________________________ Date ___________________


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(Note: Not all medical facilities will accept this form: some hospitals/doctors require that their own release be completed. And if a parent or legal guardian cannot be contacted personaily some hospitals will not treat a minor, even with a consent form, unless the problem is considered life-threatening. Check the policy in the area where your child would be treated.)

CONSENT FOR EMERGENCY MEDICAL CARE I,____________________________________________________________________________________ ( )Mother ( )Father ( )Legal Guardian

hereby give my consent to_______________________________________________________________ (Caregiver/Day Care Center)

who will be caring for my child___________________________________________________________ (Child’s Name) (Birth Date) for the period ________________________ to ______________________________ to arrange for emergency medical/surgical/dental care and treatment (including diagnostic procedures) necessary to preserve the health of my child. I acknowledge that I am responsible for all reasonable charges in connection with any care and treatment rendered.

Print Name: ______________________________

Pediatrician: ______________________________

Home Address: ___________________________ ________________________________________

Address: _________________________________ _________________________________________

Home Telephone: _________________________

Telephone: _______________________________

Business Telephone: _______________________ Name & Address of Primary Health Insurance Carrier: __________________________________ _________________________________________

Child’s Allergies, If any: _____________________ _________________________________________ Chronic Illnesses, If any: ____________________ _________________________________________

Group Number: ___________________________ Agreement Number: _______________________

Medicines Child is Taking: ___________________ _________________________________________

Signature: ___________________________________________________________________________ (Mother, Father or Legal Guardian) (Date) IN CASE OF AN EMERGENCY I CAN BE REACHED AT: (phone number) ________________________


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IMMUNIZATION POLICY

The Bureau of Communicable Disease Control of the New York State Department of Health has

legal authority to ensure that schools throughout the state comply with Section 2164(7)(a) of the

Public Health Law related to immunization requirements for school entry. Public Health Law

Section 2164(7)(a) requires that:

No principal, teacher, owner or person in charge of a school shall permit any child to be admitted to such

school, or to attend such school, in excess of fourteen days, without the certificate provided for in

subdivision five of this section or some other acceptable evidence of the child's immunization against

poliomyelitis, mumps, measles, diphtheria, rubella, varicella, hepatitis B and, where applicable,

Haemophilus influenzae type b (Hib); provided, however, such fourteen day period may be extended to not

more than thirty days for an individual student by the appropriate principal, teacher, owner or other

person in charge where such student is transferring from out-of-state or from another country and can

show a good faith effort to get the necessary certification or other evidence of immunization.

Abide in the Vine Child Care Center is considered a “school” and must uphold the above

mentioned Public Health Law. As a parent I will abide by the following Immunization Policy:

1. All immunizations MUST be kept current. Copies of updated immunization records will be given to the

AVCCC office after every vaccination. The immunization record must be an official document from a

health care provider indicating the immunizations given and the dates of administration.

2. If I fail to keep my child(ren) up to date with their immunizations – they will not be allowed to attend

AVCCC.

3. AVCCC will send out 3 reminders per year for updated immunization records… once in January, May, and

September.

4. A child may be exempt from one or more of the required immunizations for medical or religious reasons.

a. A medical exemption is given when a valid contraindication to vaccination exists. The medical

exemption must be certified by a physician licensed to practice in the State of New York and must

specify which immunizations are contraindicated and why.

b. A religious exemption is a written and signed statement from the parent, parents or guardian of

such child, stating that the parent, parents or guardian objects to their child's immunization due to

sincere and genuine religious beliefs which prohibit the immunization of their child.

It is the right and responsibility of AVCCC to accept or reject a medical or religious exemption. If

accepted - I understand this leaves my child susceptible to illness and my child will need to be removed

from AVCCC for at least 21 days should any other child exhibit a disease that would have been covered by

an immunization.

________________________________ ______________________________

Parent Name Parent Signature

________________________________ ______________________________

Child’s Name Date

Received by: ________________________________ ____________________

Director’s Signature Date Rec’d


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TUITION AGREEMENT

By signing this agreement, I acknowledge and agree to the following

statements set forth by the Board of Directors of Abide in the Vine Child Care

Center:

1. Tuition is due when my child arrives at Abide in the Vine Child Care Center

on the first day of attendance each week.

2. I understand that tuition is due even in the case of absences (illness,

vacation, time off of work, and our six vacation days).

3. I understand that if my child’s hours of attendance change, my tuition may

also change.

4. I understand that the fee schedule may change over time, and I agree to pay

my child’s tuition based on the current fee schedule approved by the Board

of Directors.

5. I understand that delinquent tuition could lead to the removal of my child

from the program. If an account becomes more than two weeks delinquent,

the child will not be permitted to attend. The position will be forfeited to

another client.

6. Non-Payment of Tuition could lead to collection or legal activity to recover

monies owed.

7. Two week written notice must be given before withdrawing the child from

the program. Failure to do so will require a two week payment.

________________________________ ______________________________

Parent Name Parent Signature

________________________________ ______________________________

Child’s Name Date

Received by: ________________________________ ____________________

Director’s Signature Date Rec’d


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PHOTO CONSENT I DO / I DO NOT give permission for my child ____________________________ (Child’s Name)

to be photographed while attending Abide in the Vine Chile Care Center. I understand that such

photographs may be included in displays both in the classroom, as well as other areas within the

Center.

I DO / I DO NOT give permission for my child’s picture to appear in promotional material

distributed by Abide in the Vine Child Care Center.

_____________________ ___________ _____________________ ___________

Parent’s Signature Date Parent’s Signature Date

Topical Over-the-Counter Ointments | Parental Authorization

I, ___________________________ (Parent/Guardian), give permission to the staff of Abide in

the Vine Child Care Center to administer the following over-the-counter ointments in their

original containers to my child ____________________(Child’s Name).

Diaper Cream: □ Yes □ No _______________________________________ (Brand Name)

Special Instructions: ____________________________________________________

Teething Gel: □ Yes □ No _______________________________________ (Brand Name)


Sunscreen: □ Yes □ No _______________________________________ (Brand Name)


Insect Repellant: □ Yes □ No _______________________________________ (Brand Name)


Other (Specify): □ Yes □ No _______________________________________ (Brand Name)


I am hereby verifying that these products have been previously applied to my child with no

allergic reactions noted and that I do not hold Abide in the Vine Child Care Center or its staff

responsible for any such reaction if it does occur.

_____________________ ___________ _____________________ ___________

Parent’s Signature Date Parent’s Signature Date

These products must be in a correctly labeled original bottle or container with your child’s first and last

name. Please give it to your child’s teacher. DO NOT STORE IN YOUR CHILD’S BAG.


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Abide in the Vine Child Care Center Emergency Notification Opt-In/Out Form

IN THE EVENT OF AN EMERGENCY: Abide in the Vine Child Care Center utilizes

multiple resources to alert our parents and staff of emergencies and closings. In the event of an

emergency or closing we utilize WBNG TV (Binghamton Channel 12) which includes

www.wbng.com. We have an emergency information phone line, 699-1511, which provides a

recording of up to date information. We also use a service that will send out automated phone

calls and/or text message alerts in the event of an emergency or closing. You may opt-in or out

of receiving automated calls by using this form.

OPT-IN/SUBSCRIBE TO AUTOMATED PHONE CALLS

I affirm that I am authorized to act on behalf of the following phone number(s) and request they

be added to receive automated phone calls in the event of an emergency or closing at Abide in

the Vine Child Care Center:

Phone #1 __________________________ Phone #2 __________________________

Phone #3 __________________________ Phone #4 __________________________

By signing below I hereby agree to opt-in/subscribe to receive automated emergency notification

calls to the above phone number(s) from Abide in the Vine Child Care Center... I understand

that I will only receive an automated call in the case of an emergency or closing at Abide in the

Vine Child Care Center. I understand it is my responsibility to keep my phone numbers up to

date and that I can opt-out/unsubscribe at any time by notifying the office. (Note: To sign up

for TEXT Alerts – you MUST follow the steps below under Texting Notification section

below).

Signature ____________________________________ Date ___________________

OPT-OUT/UNSUBSCRIBE FROM AUTOMATED PHONE CALLS

By signing below I hereby opt-out/unsubscribe from receiving automated emergency notification

calls from Abide in the Vine Child Care Center. I do NOT want to receive automated phone

calls. I prefer to receive a personal phone call.

Signature ____________________________________ Date ___________________

TEXTING NOTIFICATIONS

Abide in the Vine Child Care Center also offers a text alert subscription service. You may

automatically opt-in/subscribe to receive text alerts on your cell phone by texting

"AVCCC" to 80123 on your mobile phone. You can opt-out/unsubscribe at any time by

texting "STOP" to 80123. Our emergency alert text service is free. However, standard text

messaging fees from your wireless carrier may apply. Please check with your mobile phone

carrier if you aren't sure what fees apply when you send and receive text messages.


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Abide in the Vine Child Care Center 1277 Taylor Rd., Owego, NY 13827

Helpful Information for Teachers

Child’s Name _______________________________ Birthday _____________

List siblings and their ages ________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Are there other members of the household? If so, list name, age, and relationship:

______________________________________________________________________________

______________________________________________________________________________

Does your child nap? ___________________ When? _______________________

What time does your child go to bed at night? _______________ Wake up? _______________

Does your child have any special fears? _____________________________________________

_____________________________________________________________________________

Does your child have any problems with vision or hearing? □ Yes □ No

If so, please explain _____________________________________________________________

Does your child have any health problems that we should be aware of? □ Yes □ No


_____________________________________________________________________________

Are there any foods or drinks that your child should not have? □ Yes □ No


What does your child usually eat for breakfast? _______________________________________

_____________________________________________________________________________

Do you have any concerns about any aspect of your child’s development? □ Yes □ No


______________________________________________________________________________


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Age at which your child:

Crawled on hands and knees_________ Sat alone _________ Walked _________

Named simple objects _________ Slept through the night _________

Is any language other than English used in the home? □ Yes □ No

If so, please describe ___________________________________________________________

List illnesses your child has had __________________________________________________

____________________________________________________________________________

Does your child have frequent colds? □ Yes □ No Earaches? □ Yes □ No

Sore throats? □ Yes □ No Stomachaches? □ Yes □ No Fevers? □ Yes □ No

Has your child had any serious accidents or operations? □ Yes □ No

If so, please describe ____________________________________________________________

_____________________________________________________________________________

Does your child have any allergies? □ Yes □ No


Does your child take any regular medication? □ Yes □ No


When was your child last to a doctor? ____________________ Dentist? ___________________

Are there any special medical, physical, or emotional needs that the school or staff should be

aware of? □ Yes □ No If so, please describe ___________________________________

______________________________________________________________________________

How much television does your child generally watch every day? _________________________

What are your child’s favorite activities? ____________________________________________

_____________________________________________________________________________

What does your child enjoy doing with mother? ______________________________________

_____________________________________________________________________________

What does your child enjoy doing with father? _______________________________________

_____________________________________________________________________________


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Does your child play well alone? □ Yes □ No In groups? □ Yes □ No

Are there neighborhood playmates? □ Yes □ No

If so, with what age children does your child usually play? ______________________________

Does your child accept correction easily? ____________________________________________

What is the method of behavior control used in your home? _____________________________

_____________________________________________________________________________

Please circle items below that describe your child:

Happy Aggressive Friendly Moody Clumsy Dependent

Stubborn Impulsive Fearful Quiet Good-natured Even-tempered

Attentive Sympathetic Shy Sleepy Other:_________________________

Has your child learned to:

Listen to stories? □ Yes □ No Recognize and name common objects? □ Yes □ No

Follow simple directions? □ Yes □ No Throw and catch a ball? □ Yes □ No

Other? (Please note additional significant accomplishments) _____________________________

_____________________________________________________________________________

Has your child had group play experience? □ Yes □ No

Has your child been cared for by someone besides the family? □ Yes □ No


_____________________________________________________________________________

Has your child gone to preschool or daycare before? □ Yes □ No

Please describe previous experiences _______________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

What do you hope will be included in your child’s preschool program?

______________________________________________________________________________

______________________________________________________________________________


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How often does your baby take a bottle? ____________________________________________

Do you warm your baby’s bottle? _________________________________________________

After how many ounces do you usually burp your baby? _______________________________

How many ounces does your baby take at one feeding? ________________________________

If your baby is on a strict schedule, do you wake him/her to eat? _________________________

If your baby no longer takes bottles and is on table food, please list the foods your baby will not

eat – and if you prepare/serve certain foods a specific way (ex: sandwich broken into small

pieces or cut in half…): _________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Does your baby enjoy tummy time and/or playing on the floor? __________________________

Does your baby like to swing? ____________________________________________________

What do you do to put your baby to sleep? (ex: rocking, walking, falls asleep on his/her own in

crib…): _____________________________________________________________________

Is there anything else you would like us to know?

_____________________________________________________________________________

_____________________________________________________________________________

We request that at least one change of clothes be sent with your child each day. Please be

sure to have all your child’s items labeled with his/her name.

If you have any special instructions for your child’s care, please write them out for us to

have on file. We request to be informed of anything that may affect your baby’s day (ex:

having shots the day or two before coming in, not sleeping well the night before, not feeling

well, etc.).

Please feel free to talk to us about your baby’s care and to express any concerns that you

may have. We look forward to caring for your baby and watching him/her grow, along

with you.


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AVCCC Parent Permission Slip for the different stages of Infant Feeding

Please fill in the blanks…

Child’s Name: _____________________________________ Date: _________________

My child may only have: (Check all that apply)

________ formula

________ breast milk

________ baby food

________ food

________ cafeteria food

**IMPORTANT: It is recommended by the state for the parent to bring bottles already

made. However, if you prefer for us to make your baby’s bottles, we need written permission

and a feeding schedule. If you would like us to make your baby’s bottles, please fill in the

blanks below.

I, __________________________ (Parent/Guardian), give my permission to the staff at

AVCCC to mix (name of formula) __________________________ according to the

directions on the container. (If you mix it differently than on the container please write your

directions in the following space provided).

We are a breastfeeding friendly center. A special room is provided for your privacy and

convenience… Please indicate below whether you plan to breastfeed your child.

I, __________________________ (Parent) plan to breastfeed my child only. □ Yes □ No

PARENT’S SIGNATURE: ____________________________________

It is a choking hazard for children under the age of two to eat hot

dogs or grapes.


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Abide in the Vine Child Care Center 1277 Taylor Road

Owego, NY 13827

607-687-2422

Dear Families at AVCCC,

In our efforts to provide your children with the best possible care, AVCCC

has established a hot lunch program in our center. This program will be available

to all students. We have designed a menu that is nutritious and well-balanced, and

has been reviewed and approved by a registered dietitian.

Due to the increased cost of the hot lunches, AVCCC is pursuing monetary

assistance through CACFP program (Children and Adult Care Food Program).

The application process takes approximately three months to complete, and

requires each of our attending families to fill out an income eligibility application

(attached).

Will you please fill out the attached application, place it in the envelope

provided, and return it to the tuition box? Your honesty and prompt fulfillment of

these applications is greatly appreciated, and confidentiality is guaranteed.

Thank you, as always for your continued support of our center. We are

excited to work with you to meet this important goal.

Always,

Mary Coveney

Food Service Director


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Understanding the CACFP Food Program Dear Parents,

Abide in the Vine Child Care Center is very proud of our food program. We are part of the Federal

government’s food program called CACFP. CACFP is an acronym for “Child and Adult Care Food

Program”. We would like to share some interesting facts with you concerning the CACFP program and

what this means for your baby as he/she eats here at AVCCC.

We would like to give you some information to help you decide if you want to take part in this

program for your baby. When a baby is enrolled into the center you will have to fill out a lot of paper

work to let us know important information. One of these papers is the CACFP Form.

Birth to 3 months:

When an infant is only on breast milk or formula that the parent provides your baby can still be on the

CACFP program. If you come to the center and breastfeed your baby then you cannot be on the

program.

4 months to 7 months:

Breakfast: Will be breast milk or formula

Lunch: Will be breast milk or formula and a veggie or fruit and cereal

Snack: Will be breast milk or formula

As the parent if you would like your baby to be fed baby food for breakfast just ask your baby’s

teacher and we will be glad to do that. All this is on the CACFP program.


Breakfast: Will be breast milk or formula and whole fruit with cereal.

Lunch: Will be breast milk or formula and a whole jar of veggies, ½ jar of Meat and ½ of jar of fruit.

Once you want your baby to start being introduced to baby food… all you have to do is tell your

teacher that your baby is ready for table food and we will provide Table food for your baby.

(Introduction to table food usually starts around 11 months and we only start with soft foods

combined with baby food)

Snack: Will be breast milk or formula or milk teething biscuits, arrowroot Cookies, or puffs.


Breakfast, Lunch and Snack: Will be whole milk and what the kitchen menu is serving.

If your child is having a hard time with table food after turning a year old, then the parent will need to

supply either baby food or table food the baby will eat. As the parent, if you bring in just baby food

we will still try our table food.

That is how the food program works. We will be happy to work with you has much as we can to

make the food program work for you and your baby.

There are ways to vary the eating pattern and still be part of the program. Please talk to your Baby’s

teacher when you have any questions or concerns about when or what your baby should be eating.

Thank you for allowing us here at Abide in the Vine Child Care Center to care and love your baby.


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DSS Parents

Once your child has entered AVCCC it is your responsibility to make sure all costs are covered.

What this means is that if you decide to put your child into daycare before DSS accepts your

application you are responsible for the total cost until DSS approves you. Sometimes there is a

delay before DSS accepts you into their program. We encourage parents/guardians to make sure

all DSS is finalized before enrolling their children into our program.

My child (Child’s Name) ________________________________________ will attend AVCCC

on the following days:

□ Monday □ Tuesday □ Wednesday □ Thursday □ Friday

We accept children on a full time basis only. Full time care is based on our weekly rate for your

child’s age. This rate has to be met every week regardless if parents pay out of pocket or if it is

DSS subsidized. DSS does not cover days that your child does not attend. As a DSS recipient I

understand it is my responsibility to pay out of pocket for days my child does not attend

AVCCC.

Signature: ____________________________________ Date: _______________

Full Time Care

Here at AVCCC we have only have full time slots available. This statement is to make sure that

you understand that in the event that your child goes from full to part time we may remove them

from our program.

Full time care is based on our weekly rate for your child’s age. This rate has to be met every

week regardless if parents pay out of pocket or if it is DSS subsidized.

Signature: ____________________________________ Date: _______________

Parent Handbook

By signing below I acknowledge that I have received a copy of the AVCCC Parent Handbook

and understand its contents. I agree to abide by the AVCCC policies as set forth in the parent

handbook.

Signature: ____________________________________ Date: _______________

abide in the vine child care center · statements set forth by the board of directors of abide in...

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