PRE-ENROLLMENT CHECKLIST

KiDDIETAcAIEMY,EDucA11oNi CHILD CAREINFANT SAFE SLEEP POLICYFOR PARENTS/GUARDIANSSudden Infant Death Syndrome (SIDS) is the unexpected death of a seemingly healthy infant for whom no cause ofdeath can be determined based on an autopsy, an investigation of the place where the infant died and a review ofthe infant’s clinical history.In the belief that proactive steps can be taken to lower the risk of SIDS in the child care setting and thatjarents andchild care professionals can work together to keep infants safer while they sleep, all Kiddie Academy’ Child CareLearning Centers practice the following safe sleep policy.Safe Sleep Practices and 6.17.All child care staff working in the infant room, or child care staff who may potentially work in the infantroom, will receive training in our Infant Safe Sleep Policy.Infants will always be placed on their backs to sleep unless there is a signed sleep position medical waiverform on file. In that case, a notice will be posted on the infant’s crib.The American Academy of Pediatrics recommends that infants be placed on their backs to sleep; butwhen infants can easily turn over from the back to the stomach, they can be allowed to adopt whateverposition in which the prefer to sleep.All Kiddie Academy staff should follow this recommendation by the American Academy of Pediatrics.However, child care staff can further discuss with parents how to address circumstances when theirinfants turn onto their stomachs or sides.Sleeping infants must be checked periodically by staff. Staff members must be especially alert to monitorsleeping infants during the first several weeks they are in child care. (Infants under the age of 12 monthsmust be visually checked every 5 minutes and their position must be documented every 15 minutes on theInfant Sleep Chart or in Academy Link.)Steps will be taken to keep infants from becoming too warm or overheated, including regulating the roomtemperature and by not over-dressing the baby.The temperature of the infant room will be kept between 68 and 72 F.No loose bedding, pillows, comforters, bumper pads, etc. will be used in cribs.Appropriately sized sleep sacks are recommended in place of sheets and blankets.No toys or stuffed animals will be placed in cribs.A safety-approved crib with a firm mattress and tight-fitted sheet will be used.A crib is the only location in which children will be allowed to sleep. Any infant who falls asleep in anotherlocation will be immediately moved to his or her crib.Infants will be placed (one) 1 foot from the bottom of the crib to sleep.Only one infant will be in each crib at a time, unless the academy is being evacuated in an emergency.No smoking is permitted in the infant room or on the premises.A written copy of this Infant Safe Sleep Policy will be provided to infant room parents/guardians prior toenrollment.A written note from the child’s physician is required if it is necessary to deviate from this Safe Sleep Policy.I, the undersigned parent or guardian of(child’s full name), do herebystate that I have read and received a copy of the Kiddie Academy Infant Safe Sleep Policy and that the academy’sDirector/Owner/Operator f or other designated staff member) has discussed the Kiddie Academy Infant Safe SleepPolicy with me.Date of Child’s Enrollment:Signature of Parent or Guardian: Date:Signature of Kiddie Academy Supervisor:Date:One signed copy to be given to parent/guardian; one signed copy to be placed in the child’s file.@2005-2014 Essential Brands, Inc. 06/14)

THE COMMONWEALTH OF MASSACHUSETTSDepartment of Early Education and CareDEVELOPMENTAL HISTORY AND BACKGROUND INFORMATIONRegulations for licensed child care facilities requite this information to be on file to address the needs ofchildren while in care.DATE OF BIRTH:CHILDS NAME:*)Please provide information for Infants and Toddlers (marked as appropriate to the age of your child.DEVELOPMENTAL HISTORYAgebegancrawling:*Crawl?sitting:*Does your child pull up?talking:walking:*Walk with support?Any speech difficulties?SpecialwordstodescribeneedsLanguage spoken at home*Does your child use pacifier or suck thumb?*Does your child have a fussy time?*Any history of y known complications at birth?Serious illnesses and/or hospitalizations:Special physical conditions, disabilities:Allergiesi.e.asthma, hay fever, insect bites, medicine, food reactions:Regular medications:EATING HABITSSpecial characteristics or difficulties:*lt infant is on a special formula,describe its preparation in detail:Favorite foods:Foods refused:Page 1 of 3SG/LG/SADevelopmentalH istory2DlOOl22

*Is your child fed held in lap? High chair?*Does your child eat with spoon?Fork?Hands?TOILET HABITS*Are disposable or cloth diapers used?there a frequent occurrence of diaper rash?other:*Do you use: oil: powder: lotion:*Are bowel movements regular? How many per day?*ls there a problem with diarrhea? Constipation?*Has toilet training been attempted?*Please describe any particular procedure to be used for your child at the center:*What is used at home? Pottychair?Special child seat?Regular seat?*How does your child indicate bathroom needs (include special es your child have accidents?SLEEPING HABITS*Does your child sleep in a crib?Bed?Does your child become tired or nap during the day (include when and how long)?Please note: The American Academy of Pediatrics has determined that placing a baby onhis/her back to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is thesudden and unexplained death of a baby under one year of age. If your child does notusually sleep on his/her back, please contact your pediatrician immediately to discuss thebest sleeping position for your baby. Please also take the time to discuss your child’ssleeping position with your caregiver.When does your child go to bed at night?and get up in the morning?Describe any special characteristics or needs (stuffed animal, story, mood on waking etc)Page 2 of 3SG/LG/SADevelopmentalHistory2OlOol22

SOCIAL RELATIONSHIPSHow would you describe your child?Previous experience with other children/day care:Reaction to strangers: Able to play alone?Favorite toys and activities:Fears (the dark, animals, etc.):How do you comfort your child?What is the method of behavior management/discipline at home?What would you like your child to gain from this childcare experience?—DAILY SCHEDULEPlease describe your child’s schedule on a typical day. For infants, please include awakening, eating,time out of crib/bed, napping, toilet habits, fussy time, night bedtime, etc.Is there anything else we should know about your child?(Parent/Guardian Signature)Page 3 of 3(Date)SG/LG/SADevelopmentalHistory2OlOOl22

The Commonwealth of MassachusettsDepartment of Early Education and CareChild’s Enrollment FormChild InformationChild’s Name: Date of Birth:Age at Admission: Date of Admission:Child’s Home Address:Home Phone Number:Primary Language: Identifying Marks:Eye Color: Hair Color: Skin Color:Sex: Height: Weight:ParentlGuardian InformationParent/Guardian Name:Relationship to Child:Home Address:Reachable Phone Number:Email Address:Business Name:Business Address:Business Phone Number:Hours at Work:Parent/Guardian Name:Relationship to Child:Home Address:Page 1. of 2SG/LG/SAChildEnroJlmentForm2OlODl22

Reachable Phone Number:Email Addtess:Business Name:Business Address:Business Phone Number:Hours at Work:Additional InformationChild’s Physician:Address: Phone Number:Allergies/Special Diets?Individual Health Plan for child with a chronic health condition? If yes, please attach.Copies of any custody agreements, court orders, and restraining orders pertaining to the child?If yes, please attach.Speciallimitationsorconcerns?School Age OnlyCurrent School:School Address: School Phone Number:I certify that documentation of physical examination and immunizations in accordance withpublic school health requirements and lead poisoning screening in accordance with publichealth requirements are on file at my child’s school. Parent/Guardian initials:Parent/Guardian SignaturePage 2 of 2DateSG/LG/SAChilUEnrollmentForm2OlOOl22

THE COMMONWEALTH OF MASSACHUSETTSDepartment of Early Education and CareFIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORMDate of Birth:Child’s Name:I authorize staff in the child care program who ate trained in the basics of first aid/CPR to givemy child first aid/CPR when appropriate.I understand that every effort will be made to contact me in the event of an emergency requiringmedical attention for my child. However, if I cannot be reached, I hereby authorize the programto transport my child to the neatest medical care facility and/or toand to secure necessary medical treatment for my child.Child’s Physician Name:Address:Phone Number:Child’s Allergies:ChronicHealthConditions:Emergency Contacts (In order to be contacted)NameAddressRelationship to childHome Phone Cell PhoneDo you give permission for child to be released to this person? Yes NoNameAddressRelationship to childHome Phone Cell PhoneDo you give permission for child to be released to this person? Yes NoNameAddressRelationship to childHome Phone Cell PhoneDo you give permission for child to be released to this person? Yes NoHealth Insurance Coverage Policy#Parent/Guardian Name:Phone CellParent/Guardian Name:Phone CellParent /Guardian SignatureDate (valid for one year)SG/LG/SAEmergencyMedica lConsent2OlOQl22

THE COMMONWEALTH OF MASSACHUSETTSDepartment of Early Education and CareSmall Group and Large Group Transportation Plan and AuthorizationCHILDS NAME:MY CHILD WILL ARRIVE AT THE PROGRAM:MY CHILD WILL DEPART FROM THE PROGRAM:PARENT DROP OFFPARENT PICK UPSUPERVISED WALKSUPERVISED WALKUNSUPERVISED WALKUNSUPERVISED WALKPUBLI C/PRIVATENANPUBLI C/PRIVATE/VANPROGRAM BUS/VANPROGRAM BUS/VANCONTRACTNANPRIVATE TRANS. ARRANGED BY PARENTOTHERCONTRACT/VANPRIVATE TRANS. ARRANGED BY PARENTOTHERCHILDS NAME:MY CHILD WILL ARRIVE AT THE PROGRAM:MY CHILD WILL DEPART FROM THE PROGRAM:PARENT DROP OFFPARENT PICK UPSUPERVISED WALKSUPERVISED WALKUNSUPERVISED WALKUNSUPERVISED WALKPUBLI C[PRIVATENANPU BLI C/PRTVATE/VANPROGRAM BUS/VANPROGRAM BUS/VANCONTRACT/VANCONTRACTNANPRIVATE TRANS. ARRANGED BY PARENTPRIVATE TRANS. ARRANGED BY PARENTOTHERPARENT /GUARDIAN SIGNATUREOTHERDATEREFER TO FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM FOR RELEASE 6

Commonwealth of MassachusettsDepartment of Early Education and CareMEDICATIONCONSENT606FORMCMR 7.J1(2)(b)Name of child:Name of medication:Please J one of the icipated Non-Prescription for mild symptomsTopicalNon-Prescription(appliedtoopen wound! broken skin)My child has previously taken this medicationMy child has not previously taken this medication, but this is an emergency medication and I givepermission for staff to give this medication to my child in accordance with his/herindividual health care planDosage:Date(s)be given:medication toTimes medication to be given:Reasons for medication:Possible side effects:Directions for storage:Name and phone number of the prescribing health care practitioner:Child’s Health CarePractitioner Signature(parent or guardian)I,givespermission(print name)toauthorize educator(s) to administer medication toParent/GuardianFor topical,mychildasindicated above.Signaturenon-prescriptionNOT appfied to open wound Ibroken skinDateonly)(parent signatureSG/LG/SAMedicationConsent2OlOOl22

THE COMMONWEALTH OF MASSACHUSETTSDepartment of Early Education and CareOFFSection 1-SITEACTIVITIESPERMISSIONFORMProgram completes prior to parental consentProgram:Name of Educator(s) responsible for child:Name of off-site location and address:Date of off-site activity:Time Leaving Program: Time Returning to Program:Method of Transportation:Fee associated with activity (if any):**NOTE** Each child must carry on his/her person the name, address, and telephone number of staff or child careprogram whenever she/he is off the premises in care of the program.Section 2—ParenUGuardian completes prior to off-site activityI give permission for my child to attend the above identified off-site activityChild’s Date of Birth:Child’s Name:Parent’s/Guardian’s Name:Phone Number:I authorize child care program staff to secure necessary emergency medical treatmentName of child’s Physician, Address, phone number:Child’s allergies, health conditions, or Individual Health Plan:Health Insurance Plan and Policy #:Emergency Contact Name:(Parent/Guardian Signature)Contact #:(Date)This form must accompany each child on the off-site activitySG/LG/SAOffSitePermission2OlOOl22

PRE-ENROLLMENT CHECKLIST 4-6 Weeks Prior to Start Date _Set up enrollment meeting with Director _Confirm Start Date:_ . HPSOR\HHV DJDLQVW DQ\ DQG DOO OLDELOLW\ IRU DQ\ DQG DOO LQMXULHV WR P\ FKLOG DULVLQJ IURP RU UHODWHG WR WKH LWHPV OLVWHG RQ . form on file. In