CDC Application Packet Step 1 of 6 16% Parents:Please fill out this packet completely. At the bottom of this form, attach the following digital paperwork: 1. Copy of Parent’s Social Security Card 2. Copy of Child’s SS Card & Birth Certificate 3. Copy of Child’s Current Immunization Records 4. Copy of Parent ID Child's Name* First Middle Last Parent's Name First Last Providence House Child Development Center Checklist for New Family Orientation* I agree to these rules.o Tour of the center o Introduction of teachers o Transition period (parent/child/teacher interaction) o Admission Requirements: - Enrollment Packet - Up to date Shot Records - Parental Permission and Authorization Form - Copy of Parent’s Soc. Sec. Card and Child’s Birth Certificate - CCAP Signature Page o Hours of Operation/Daily Routine o The center does not open until 7:30 a.m.; please do not bring your child to the center early. o Child must walk in and out with an adult. o Parent Handbook o Signing In/Out procedure o Third Party Release (authorized persons to pick-up your child) o Medical History (allergies, health problems, development) o Concerns/Complaint Procedure o Diaper bag/Change of clothes o Proper clothing for weather o Bring child by 8:30 a.m. or notify director if you will be late or leave early. o Violent behavior not allowed (guns, weapons, etc.) o Do not bring your child’s personal toys, candy, or food. o Health policy o Immunizations o Mandatory health check each morning upon arrival at the center. Your child’s teacher will complete the health check and you must stay until completed in case any questions arise. o Hand washing – parents’ responsibility upon arrival in the classroom each morning.SignatureCopy of Parent’s Social Security CardMax. file size: 128 MB.Copy of Child’s SS Card & Birth CertificateMax. file size: 128 MB.Copy of Child’s Current Immunization RecordsMax. file size: 128 MB.Copy of Parent IDMax. file size: 128 MB. Master CardChild's Name First Last Gender* Male Female Birthdate MM slash DD slash YYYY Mother's InformationName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer Home PhoneWork PhoneCell PhoneFather's InformationName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer Home PhoneWork PhoneCell PhonePerson with whom the child lives: Child’s Doctor: First Last Doctor’s Phone:Child’s Dentist: First Last Dentist’s Phone:Emergency Contact 01: First Last PhoneEmergency Contact 02: First Last PhoneEmergency Contact 03: First Last PhoneAllergy InformationDoes your child have any food allergies? Yes No Does your child have any other allergies? Yes No Does your child have any dietary restrictions? Yes No Please explain any “yes” answers here:Authorized ReleaseMy child has permission to be released to the following individuals, child care facilities, or transportation services, in addition to emergency contact persons listed above. Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship Medical Consent I authorize the facility to secure emergency medical treatment for my child.Signature Master Card Page 2May your child be photographed? Yes No LanguageDoes your child speak/understand English? Yes No Is there a second language spoken in the home? Please tell us which language, if applicable. Physical BackgroundHas your child had any serious illnesses, operations, or accidents since birth? Yes No If yes, please describe:What health problems has your child had in the past?What health problems does your child have now?Any physical disabilities? Yes No Please describe any physical disabilities:Please list any medication your child takes regularly:Has your child ever been hospitalized? Yes No Please describe:Does your child have any recurring chronic illness or health problems? (such as asthma, eczema, etc.) Yes No Please describe: Relationships and InterestsHow does your child get along with other children?Does your child have any previous childcare experience? Yes No Is your child friendly? Yes No Is your child shy? Yes No Is your child aggressive? Yes No Is your child withdrawn? Yes No Does your child play well alone? Yes No How does your child get along with adults?What are you child’s favorite toys?How does he/she show their feelings?How does he/she react to frustration?What are your child's fears or concerns?Is your child frightened by animals, rough children, loud noises, darkness, storms, or anything else? Please describe:How do you feel your child will adjust to our childcare setting?Who does most of the disciplining to your child?What is the best way to discipline your child?How do you comfort your child?Does your child use a special comforting item? (such as a blanket, stuffed animal, or doll). Please describe:Infant/Toddler InformationBottle Permission/Feeding ScheduleIs your child an infant / toddler? Yes No Preferred Infant Formula Type: Alternate Infant Formula Type: Approximately _______________________ ounces every _______________________ hours. Water: _________________________ ounces. Juice: ____________________________ ounces. Cereal Type: Approximately _______________________ ounces every ________________________ hours. Baby Food: _________________________ jars every _____________________ hours. List types of baby food:Table Foods: Yes No Whole Milk: Yes No Sippy Cup: Yes No Infant Consent I verify that my infant is able to hold his/her own bottle and I give permission for the staff to give my child his/her bottle in the crib.Please understand that the Providence House Child Development Center’s practice is to feed on demand. That is, when an infant is crying to be fed at times other than those listed above, the baby is fed. When an infant refuses a bottle or feeding of solid foods, the baby is not force fed. We will make every effort to follow a parent’s directions on feeding. Parental Permission and Authorization01 I authorize Providence House Child Development Center to care for my child during the time he/she is in the facility or participating in a facility sponsored field trip and to administer and/or obtain emergency medical treatment for my child in the event that I cannot be reached.02 I authorize the center to allow my child to hold his/her bottle in his/her crib.03 I authorize my child to participate in water activities at the Child Development Center.04 I allow the Child Development Center staff to photograph my child for use in the center.05 I will allow my child to be monitored on the secure website by Providence House senior staff, in which Ms. Miller, Director, has access to in her office. There is a camera in every childcare classroom.06 I verify that I have received a copy of the Policies and Procedures Parent Handbook for the Providence House Child Development Center.Parent's SignatureThis signature agrees to all of the above. Providence House Child Development Center Media Release* My child may be photographed and identified by name. I do not permit my child to be photographed or identified. We may be contacted by news media concerning issues related to child care and homelessness. We need your permission to allow photographs of your children to be used on television, newspapers, and other publications. Usually children are not identified by name. Let us know your preference. Please select the statement that applies to you and your child, and sign this release form. SPECIAL DIET STATEMENTThe child named below is a participant in the U.S. Department of Agriculture Child and Adult Care Food Program (CACFP). His/her child care provider is required to provide meals according to the minimum requirements for the CACFP.In place of breast milk or iron fortified infant formula Infant (8 through 12 months) approved to be served: Select All whole milk reduced fat (2%) milk low-fat (1%) milk or skim (nonfat) milk Non-Iron-Fortified Infant Formula substituted for Iron-Fortified Infant Formula for an infant Under 12 months. Yes No NOTE: Infants do not require a Special Diet Statement for soybean based formula Milk allergy Yes No Special instructions if any. List recommended alternate foodsIron-Fortified Infant Cereal has been eliminated from the infant’s diet (ages 4 through 11 months). List recommended alternate foods:Other. List recommended alternate foods:Brief explanation. Δ
