Circle Of Friends Preschool

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Circle of Friends PreschoolTwo-tsy PopsThe two-tsy pop class is a mommy and me program. Mommy’s accompany the child toclass for the 2 hour session.Child’s NamePlacement #BirthdateName your child goesDateZipAddressParent/Guardian 1 NameHome PhoneParent/Guardian 2 NameParent/Guardian 1 Cell #*EncloseParent/Guardian 2 Cell #your nonrefundable registration fee of 75.00 andenclose it with your registration forms.Please designate placement choice2 years old byAugust 31Monday 9:15-11:15Thursday 9:15-11:15OR#Class Two-tsy PopsSessionMonday or Thursday Office Use Only14/16

Student Information FormChild’s Full NameBirth dateName your child goes byGender:MaleorParent/Guardian’s NameRelationshipParent/Guardian’s NameRelationship//FemaleChild lives with:Sibling NameAgeSibling NameAgeSibling NameAgeSibling NameAgeFamily PetsWe want your child to have a positive preschool experience. Please help us get to know them by sharing thefollowing information.1. A brief description of your child’s personality:2. Fears your child may have (dogs, sirens, etc.)3. Any unusual experiences your child may have had (moving, hospital stay, loss of someone dear:4. Your child’s favorite toys or games:5. Language spoken at home:6. Which is your child’s dominant hand?Right7. Type of previous group or preschool experience?LeftYesNoUndeterminedWhere?Circle of Friends Preschool, 805 Columbia Ridge Drive, Vancouver, WA 98664360-696-9926

Dismissal & EmergencyContact FormChild’s Name:Please list a minimum of two emergency contacts other than parents/guardians. We will makeevery effort to contact you in the event of an emergency. Should we not be able to get ahold ofyou, you authorize our staff to contact the following people.You may also authorize people other than your child’s parents/guardians to pick up your childfrom school. If someone not listed above is picking up your child, they must show their driver’slicense as identification, which should correspond with the note given to the teacher at thebeginning of class. If the information is conflicting, the teacher is not to let the child go until properconfirmation has been made.For each contact, check the appropriate boxes below. Your parent/guardian information is alreadyon file.In the event there is a medical emergency involving my child during the school hours at Circle ofFriends Preschool, and I am unable to be contacted, I hereby give my permission for appropriatemedical treatment to be given to my child by a licensed healthcare professional.Dismissal Authorization and Emergencies ContactsNamePhone ()RelationshipNamePhone ()RelationshipNamePhone ()RelationshipNamePhone ()RelationshipNamePhone ()RelationshipDoes this personhave permissionto pick up yourchild?Is this personan YesNoNoYesYesNoNoCircle of Friends Preschool, 805 Columbia Ridge Drive, Vancouver, WA 98664360-696-9926

Medical ReleaseI (We) the undersigned, parent or legal guardian of.a minor, do hereby authorize and consent for Circle of Friends Preschool to seek medical treatmentdeemed necessary in the event of an emergency, accident or sudden illness. Every attempt will bemade to immediately make contact with a parent.I (We) will assume any expense incurred by such treatment.Doctor preferredPhoneHospital preferredPhoneInsurance CompanyPolicy HolderPolicy NumberGroup NumberI (We) do not hold the above named, or Circle of Friends Preschool responsible or liable for anyaction necessary in the emergency care of my (our) child.SignatureDateCircle of Friends Preschool, 805 Columbia Ridge Drive, Vancouver, WA 98664360-696-9926

WASHINGTON STATE PATROLIdentification and Criminal History SectionPO Box 42633Olympia WA 98504-2633(360) 534-2000http://watch.wsp.wa.govApproval Date:Staff initial.:.REQUEST FOR CONVICTION CRIMINAL HISTORY RECORD (RCW 10.97)Expiration Date:Student name:Date submitted:Return this form to the director of Circle of Friends Preschool a minimum of two weeks prior toworking in the classroom. Include a copy of your driver's license or state-issued identification with thisform.Complete page 1, section A below and all of page 2.SUBJECT INFORMATION: (Please type or print clearly)Applicant's Name:LastFirstMiddleAlias/Maiden Name:Date of Birth:Race:Sex:Month/Day/YearREQUESTOR INFORMATION: (Please type or print clearly)DATE:/ /Mo DaySharon Wallenborn, DirectorYr.(print) Name/Title of RequestorProvide e-mail to receive background results electronically.E-mail address)Subject's Right Thumb Print (Optional)(Please type or print clearly)NameAddressState3000-240-569 (R 7/15)Phone No. (Password (must be at least 8 characters)REQUESTOR'S ADDRESS:CityRequestor's SignatureZIP Code

Page 2 - of the Washington State Patrol Identification and Criminal History CheckIn accordance with RCW 43.43.830, applicants and prospective volunteers are required to complete this disclosure form. Inaddition, applicants who have been offered employment or volunteer assignments as outlined in said law will be re-quired tocomplete a Request for Criminal History form, or fingerprinting for a background check. These requests will be forwarded to theWashington State Patrol for disclosure of any applicable charges or finding. Applicants may be employed on a conditional basispending completion of such background investigation. Volunteers will be retained on the same conditional basis. Answer YESor NO to each listed item. If the answer is YES to any item, explain in the area provided, Indicating the charge or finding, thedate and the court(s) involved.1. Have you ever been convicted of any crimes against persons as defined in Section 1 of Chapter 486, Laws of 1987, andlisted as follows: Aggravated murder; first of second degree murder, first of second degree kidnapping; first, second or thirddegree assault; first, second or third degree rape; first, second or third degree statutory rape; first or second degreerobbery; manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promotingprostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first orsecond degree criminal mistreatment?ANSWER.If YES, explain2. Have you ever been found in any dependence action under RCW 13.34.030 (2) (b) to have sexually assaulted orexploited any minor or to have physically abused any minor?ANSWERIf YES, explain3. Have you ever been found by a court in a domestic relations proceeding under Title 26 RCW to have sexuallyabused or exploited any minor or to have physically abused any minor?ANSWERIf YES, explain4. Have you ever been found in any disciplinary board final decision to have sexually abused or exploited any minor or tohave physically abused any minor?ANSWERIf YES, explain5. Have you been convicted in the past 10 years of any crime: felony or misdemeanor?ANSWERIf YES, explainPursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that the foregoing istrue and correct. Furthermore, I understand that my continued association with this organization is conditional upon thefingerprinting and/or background checks that Circle of Friends Preschool/Columbia Presbyterian Church will conduct.ORGANIZATION:Columbia Presbyterian ChurchCircle of Friends Preschool8715 St. Helens Ave.Vancouver, WA 98664I authorize Circle of Friends Preschool/Columbia Presbyterian Church to make investigation of Washington State PatrolIdentification and Criminal History Section. I further authorize this government agency to provide Circle of FriendsPreschool/Columbia Presbyterian Church with information they have regarding me. I hereby release and discharge the Circle ofFriends Preschool/Columbia Presbyterian Church and those who provide information from any and all liability as a result offurnishing this information.ApplicantSignature:Date:

Food Allergy/Intolerance StatementName of ChildBirth date1. Name of Parent/GuardianPhone2. Name of Parent/GuardianPhoneWe need to know the foods the child is allergic or intolerant to, as diagnosed by a physician,and the treatment steps to take in order to assist in treatment of an allergic reaction.List each foodFoodFood AllergyseparatelyIntoleranceSymptomsTreatment(in order of o2.3.1.YesYesNoNo2.3.By signing below, I indicate my approval for Circle of Friends Preschool staff to assist in treatment ofmy child’s immediate medical need.Parent’s SignatureDateParent’s Name(Please Print)Do you consent to releasing your child’s food allergy information to the other preschoolclassroom parents?YesNoCircle of Friends Preschool, 805 Columbia Ridge Drive, Vancouver, WA 98664360-696-9926

Emergency Plan for Food Allergic ReactionsALLERGY TO:Student’s Name:Asthma Yes*D.O.B:No*High Risk for severe reactionSIGNS OF AN ALLERGIC REACTIONSystems:Symptoms: MOUTHTHROATSKINGUTLUNG HEARTitching & swelling of the lips, tongue, or mouthitching and/or a sense of tightness in the throat, hoarseness and hacking coughhives, itchy rash, and/or swelling about the face or extremitiesnausea, abdominal cramps, vomiting, and/or diarrheashortness of breath, repetitive coughing, and/or wheezing“thready” pulse, “passing-out”The severity of symptoms can quickly change. All the above symptoms can potentiallyprogress to a life-threatening situation.ACTION FOR MINOR REACTIONIf symptom(s) are: Call: Parent/Guardian or Doctor Administer with Parental permission:medication/dose/route If condition does not improve within 10 minutes, follow steps for SevereReaction below:ACTION FOR SEVERE REACTIONIf symptom(s) are: Administer: Call: Call:Medication/dose/routeIMMEDIATELY!911(Never hesitate to call 911)Parent or GuardianParent/Guardianphone #Parent/Guardianphone #Doctorphone #Parent Signature:Circle of Friends Preschool, 805 Columbia Ridge Drive, Vancouver, WA 98664360-696-9926

Additional InformationChurch affiliation:Denomination:Who may we thank for your referral?Photo ReleaseChildren will be photographed throughout the school year during the various activities. Thesepictures may be used in publications for Circle of Friends Preschool and/or Columbia PresbyterianChurch, as well as the preschool website (no names listed) and slide shows throughout the schoolyear. Please designate below if your child’s picture may be used.Photos of ALL children will be used in Circle of Friendsyear-end slide show.Child’s NamePublications& WebsitePrivateFacebook pageYesYesNoNoParent/Guardian SignatureDateCircle of Friends Preschool, 805 Columbia Ridge Drive, Vancouver, WA 98664360-696-9926

Circle of Friends Preschool RegistrationStudent InformationChild’s Full NameDate of BirthName your child goes by:AgeGenderToday’s DateParent/Guardian ce of Employment))Work phone(Parent/Guardian)Phone(AddressZipCell(Place of Employment))Work Phone()Email address is for school communications only.Home E-mail address:Circle of Friends Preschool, 805 Columbia Ridge Drive, Vancouver, WA 98664360-696-9926

Certificate of Immunization Status (CIS)For Kindergarten-12th Grade / Child Care EntryOffice Use Only:Reviewed by:Date:Signed Cert. of Exemption on file? Yes NoPlease print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System.Child’s Last Name:First Name:Middle Initial:Birthdate (MM/DD/YY):Sex:I give permission to my child’s school to share immunization information with theImmunization Information System to help the school maintain my child’s schoolrecord.I certify that the information provided on this form is correct and verifiable.Parent/Guardian Signature RequiredDateParent/Guardian Signature RequiredDate Required for School and Child Care/Preschool Required Only for Child DateMM/DD/YYRequired Vaccines for School or Child Care EntryDateMM/DD/YYDateMM/DD/YYDocumentation of Disease ImmunityHealthcare provider use only Tdap (Tetanus, Diphtheria, Pertussis)If the child named in this CIS has a history ofVaricella (Chickenpox) or can show immunityby blood test (titer) it MUST be verified by ahealthcare provider Td (Tetanus, Diphtheria)I certify that the child named on this CIS has: Hepatitis B 2-dose schedule used between ages 11-15 a verified history of Varicella (Chickenpox). DTaP / DT (Diphtheria, Tetanus, Pertussis) Hib (Haemophilus influenzae type b) IPV / OPV (Polio) laboratory evidence of immunity (titer) todisease(s) marked below. Lab report(s)for titers MUST also be attached. MMR (Measles, Mumps, Rubella) Diphtheria Mumps Other: PCV / PPSV (Pneumococcal) Hepatitis A Polio Varicella (Chickenpox) History of disease verified by IIS Hepatitis B Rubella Hib Tetanus Measles VaricellaRecommended Vaccines (Not Required for School or Child Care Entry)Flu (Influenza)Hepatitis AHPV (Human Papillomavirus)Licensed healthcare provider signature(MD, DO, ND, PA, ARNP)MCV / MPSV (Meningococcal)MenB (Meningococcal)RotavirusPrinted NameDate

Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand.To print with immunization information filled in: Ask if your healthcare provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewidedatabase). If they do, ask them to print the CIS from the IIS and your child’s immunization information will fill in automatically. You can also print a CIS at home by signing up and logginginto MyIR at If your provider doesn’t use the IIS, email or call the Department of Health to get a copy of your child’s CIS: or 1-866397-0337.To fill out the form by hand:#1 Print your child’s name, birthdate, sex, and sign your name where indicated on page one.#2 Vaccine information: Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects againstseveral diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B,and Polio as IPV.#3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet schoolrequirements. If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section.#4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for theappropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS.Reference guide for vaccine abbreviations in alphabetical orderFull VaccineNameAbbreviationsAbbreviationsFull VaccineNameFor updated list, visit pletelistofvaccinenames.pdfAbbreviationsFull VaccineNameAbbreviationsFull VaccineNameAbbreviationsFull Vaccine NameDTDiphtheria, TetanusHep AHepatitis AMCV / MCV4MeningococcalConjugate VaccineOPVOral PoliovirusVaccineTdapDTaPDiphtheria,Tetanus, acellularPertussisTetanus,Diphtheria, acellularPertussisHep BHepatitis BMenBMeningococcal BPCV / PCV7 /PCV13PneumococcalConjugate VaccineVAR / VZVVaricellaDTPDiphtheria,Tetanus, PertussisHibHaemophilusinfluenzae type bMPSV / MPSV4PPSV / PPV23Flu (IIV)InfluenzaHPV (2vHPV /4vHPV / eVaccineMMRHBIGHepatitis B ImmuneGlobulinIPVInactivatedPoliovirus VaccineMMRVReference guide for vaccine trade names in alphabetical orderTrade NameVaccineTrade es, Mumps,RubellaMeasles, Mumps,Rubella withVaricellaRota (RV1 / RV5) RotavirusTdTetanus,DiphtheriaFor updated list, visit pletelistofvaccinenames.pdfTrade NameVaccineTrade NameVaccineTrade NameVaccineActHIB HibFluarix FluHavrix Hep AMenveo MeningococcalRotarix Rotavirus (RV1)Adacel TdapFlucelvax FluHiberix HibPediarix DTaP Hep B IPVRotaTeq Rotavirus (RV5)Afluria FluFluLaval FluHibTITER HibPedvaxHIB HibTenivac TdBexsero MenBFluMist FluIpol IPVPentacel DTaP Hib IPVTrumenba MenBBoostrix TdapFluvirin FluInfanrix DTaPPneumovax PPSVTwinrix Hep A Hep BCervarix 2vHPVFluzone FluKinrix DTaP IPVPrevnar PCVVaqta Hep ADaptacel DTaPGardasil 4vHPVMenactra MCV or MCV4ProQuad MMR VaricellaVarivax VaricellaEngerix-B Hep BGardasil 99vHPVMenomune MPSV4Recombivax HB Hep BIf you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711).DOH 348-013 December 2016

Circle of Friends Preschool, 805 Columbia Ridge Drive, Vancouver, WA 98664 360-696-9926 . Medical Release I (We) the undersigned, parent or legal guardian of . a minor, do hereby authorize and consent for Circle of Friends Preschool to seek medical treatment .

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