Learning Center Enrollment Form Learning Center Enrollment Use this form to begin the enrollment process for either of Early Childhood Alliance's Learning Centers. Step 1 of 8 12% Start Date* MM slash DD slash YYYY Location* Beacon Learning Center - 2125 Beacon St, Fort Wayne, IN 46805 Downtown Learning Center - 516 E Wayne St, Fort Wayne, IN 46802 Child Care Hours NeededApproximation is fineFrom* : Hours Minutes AM PM To* : Hours Minutes AM PM Days care is needed* Select All Monday Tuesday Wednesday Thursday Friday Primary Contact 1Name* First Last Relationship to children Address* Street Address City State / Province / Region ZIP / Postal Code County of Residence* School System* Cell Phone Number*So that we may send special announcements via text message.Phone Number For Emergencies*Email* Date of birth* MM slash DD slash YYYY Marital Status* Married Divorced Separated Single Employer/School* Please provide the name of your or employer or school.Employer/School Phone Number*Employer/School Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Work/School Hours Begin* : Hours Minutes AM PM Work/School Hours End* : Hours Minutes AM PM Work/School Days* Select All Monday Tuesday Wednesday Thursday Friday Primary Contact 2Name First Last Relationship to children Address Street Address City State / Province / Region ZIP / Postal Code County of Residence School System Cell Phone NumberSo that we may send special announcements via text message.Phone Number For EmergenciesEmail Date of birth MM slash DD slash YYYY Marital Status Married Divorced Separated Single Employer/School Please provide the name of your or employer or school.Employer/School Phone NumberEmployer/School Address Street Address City State / Province / Region ZIP / Postal Code Work/School Hours Begin : Hours Minutes AM PM Work/School Hours End : Hours Minutes AM PM Work/School Days Select All Monday Tuesday Wednesday Thursday Friday Emergency ContactsPlease enter the name and cell phone number of 2-5 emergency contacts*Emergency Contact NameCell Phone Number In the unlikely event that your child is involved in an emergency these contacts will be called if we're unsuccessful in contacting either of the primary contacts specified on previous pages.Authorized Pick-UpsI understand that my child will be released to those listed previously on the Emergency Information, or to the following people designated by me. These people are also to be contacted, in the order written, if neither parent can be reached. (Please note: According to state licensing policies, you must list at least one contact below.) Enter 1-5 individuals to designate as authorized pick-ups for this child.*NameAddressCityZip CodePhoneRelationship To Child By listing these individuals you are giving Early Childhood Alliance permission to release your child to them. If you wouldn't trust your child alone with this person then they should not be added to this list. Remember that all authorized pick-ups but be prepared to furnish a photo ID every time they pick up your child.Responsibility to update authorized pick-ups*Our staff will release your child only to individuals listed above or on the child's birth certificate. As such, it is imperative that you notify your center's staff when a change needs to be made to your child's authorized pick-up list. This ensures that your child is only released to the people you trust. I understand that it is my sole responsibility to notify Early Childhood Alliance of any and all changes to my child's authorized pick-up list.Custody Issues*According to the State of Indiana, any person listed on a child's birth certificate has legal permission to pick up the child unless legal documentation has been shared with Early Childhood Alliance stating otherwise. I understand that I need to bring a copy of appropriate documentation to be kept in my child's file when custody issues arise. Child InformationChild's Name* First Last Child's Birth Date* MM slash DD slash YYYY Child's Gender* Female Male Child's Legal Guardian's Name* First Last Child Lives With* Primary Contact 1 Primary Contact 2 Other Doctor's Name* First Last Doctor's Phone Number*Dentist's Name* First Last Dentist's Phone Number*Hospital Preference* Medications or Other Medical ConditionsAllergies/Food SensitivitiesSpecial NeedsName of person child lives with and their relationship*You selected "other" in the previous question, please provide some additional details. Does This Child Have Any Special Needs?*If you select "Yes" documentation must be provided to Early Childhood Alliance (i.e. IEP, ISTAR, IFSP) Yes No Identified special needs of your child* Who identified these special needs?* Is there any family participation in other services? First Steps Healthy Families Other You selected "Other" for services, please describe the service* How often do you participate in the aforementioned services?* Getting Acquainted With Your ChildSiblingsClick the + symbol to enter additional siblings.NameAge How often does your child see their non-custodial parent?* What would you like us to know about your child's cultural background?* Does your child take medication regularly?* Yes No What medications and for what reasons* Please list any health problems or special needs if applicableAny other information we should know in order to help us know your child better?(i.e. tubes in ears, etc.)Is this child an infant?* Yes No Has your child experienced group care before?* Yes No Where have they experienced group care before?* When did they experience this group care?* When is the child's first nursing?* : Hours Minutes AM PM Reason for leaving previous group care?* What three words best describe your child?* Favorite play materials/special interests* Pets* Is the child nursed in an hourly interval or on demand?* Hourly interval On demand What interval is the child nursed?* Is your child nursed with breast milk or formula?* Breast Milk Formula Both Name of formula* How many ounces of formula per feeding?* Formula feeding intervals* Comfort Needs*Sleep Patterns*Way to be held to be put to sleep, calmed, or when fussyWhat does your child like to eat?* Does your child feed him/herself?* Yes No Does your child have any food dislikes?* What time does your child go to bed?* : Hours Minutes AM PM What time does your child get up from bed?* : Hours Minutes AM PM Does your child nap?* Yes No How long does your child nap for?* What time does your child usually take a nap?* : Hours Minutes AM PM Does your child have a special toy to nap with?* What is your child's routine in preparation for rest?*(i.e. story time, quiet play, snack) Is your child toilet trained?* Yes No What is the normal number of bowel movements your child has daily?* Does your child use the toilet on his/her own?* Yes No, they tell an adult first Does your child need to be reminded to use the toilet?* Yes No At what time intervals should your child be reminded to use the toilet?* Does your child need help with clothing?* Yes No Does your child have certain words to indicate a need to use the toilet/bathroom?* Please list any fears your child has If you have additional children you need to enroll, we'll gather their information when you come in. Household InformationPrimary Language in Household* Safe Sleep PolicyProviding your infant with a safe environment in which to grow and learn is of extreme importance to us. To that end, our child care facility has implemented policies and procedures to create a safe sleep environment for your infant. We follow the recommendations of the American Academy of Pediatrics (AAP) and the Consumer Safety Commission for safe sleep environments to reduce the risk of sudden infant death syndrome (SIDS). SIDS is “the sudden death of an infant under one year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history.” Our written policy is as follows: All infants will be placed on their backs in safety-approved cribs unless an alternate sleep position is needed for a medical reason and a written note from the infant’s health professional is provided. This note needs to include the medical reason and to what degree the mattress needs to be inclined in centimeters/inches. Products used to control the position of the infant in sleep (wedges, etc.) will not be used. Since swaddling is not recommended in childcare, a doctor’s note is required if you would like your child under 3 months to be swaddled. You may also be asked to provide a safe swaddler if we do not have one available. Infants will not sleep on water beds, sofas, soft mattresses or other soft surfaces. Soft materials, such as pillows, quilts, comforters, sheepskins, stuffed toys and loose bedding, will not be placed in infants’ sleep environments. Infants will not share a safety-approved crib with other children. Supervised “tummy time” will be observed while the infant is awake. No smoking will be allowed in infants’ environments. Since the start of the 1994 national campaign that provided guidelines for parents, health professionals and other caregivers to place infants on their backs to sleep, the number of infants dying of SIDS has decreased. I agree to the Safe Sleep Policy* By checking this box you are indicating that you have read and understand the policy above. Consent for medical treatment of a minor child* Check if you agree to the following statementI authorize Early Childhood Alliance Staff to provide immediate first aid to my child when necessary. In the event of an emergency, I consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to the above-named Minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine at the nearest hospital. Your child's health insurance provider* Others authorized to have access to your child’s health information Please include one name per line, click the + symbol to add more lines.Medicine AuthorizationEarly Childhood Alliance staff are allowed to administer the following medicines to the aforementioned child upon the parent’s request.Will your child need medication administered during center hours?* Yes No Authorized MedicationsEnter the name of the medication that should be administered to your child upon your request along with the dosage amount, frequency of dosing, and reason for administration. One per line please, click the + symbol to add more lines.Name of medicationDosage AmountFrequency of useReason for use Other protective productsPlease check off the items you authorize the center staff to administer as needed. Sunscreen or sun block with UVB or UVA of SPF 15 or higher Insect repellant with DEET Parent OrientationEarly Childhood Alliance Centers are open Monday through Friday, 6:00 a.m. until 6:00 p.m. Please check the boxes below to indicate your understanding of the statements next to them.Scheduling We must have an emergency telephone number for parents while their children are in our care. Whenever parents are not at work, they need to notify us of an emergency number where they can be reached, and at least one alternate emergency number.Arrival and Departure I will escort my child into the building and wait with them until their temperature is taken and is under 100 and no other symptoms to be able to stay for the day. Parents are asked to not use their cell phones at drop off or pick up time. Teachers would like to use this time to exchange information about your child. I will notify the Center Manager if my child is to be absent for any reason. Children will only be released to their parents/guardian, or someone authorized by the parent. We will ask for photo identification. We will not release a child to anyone for whom the parent/guardian has not given permission for us to do so. I understand that if a staff person is concerned about the safety of my child at pick-up time because an authorized adult or I seem disoriented or displays impaired judgment, that staff person has the right to call an emergency contact. If attempts to keep the child safe from the disoriented authorized adult are unsuccessful, then the Police Department will be contacted. Personal Belongings The Child Care Center will provide all snacks, breakfast and lunch. and play and learning materials. If your child will be here for dinner, please bring in a sack lunch that they can eat during that time. Parents are asked to bring one (1) complete changes of appropriate play clothing for their children. Please dress your child(ren) according to the weather. Children go outside every day when the temperature is above 25 degrees, including the wind chill factor. Be sure to include hats, boots, mittens, etc. on colder days. All clothing should be visibly marked with the child's name. Soiled clothing will be put in a plastic bag and given to parents at pick up time. Children are asked to bring a small blanket/cover to use at naptime and may bring a special comfort item, (i.e. stuffed animal). We ask that all other toys be left at home to eliminate lost or broken toys. Bring all materials, devices and books needed to complete e-learning, Wi-Fi will be provided. You will need to provide all diapers/wipes and pullups for children that are not yet potty trained. Because we have a limited amount of space, all strollers, diaper bags, etc., need to be taken with you and not left in the Center. Car seats can be left if needed. Food/Nutrition We are a peanut-restrictive center. Children requiring special diets (i.e. allergies, food sensitivities, supplements, or other changes outside state guidelines) will need to bring their own food and snacks for the day. A feeding plan is required for all infants or young toddlers not on table food. Infants will need to provide their own food, bottles and snacks each day. Mark your child’s food/bottles clearly. Any children using a sippy cup will need to provide two/day and we will send them home daily for cleaning. Any treats brought in for special holidays or occasions must be commercially prepared and in unopened packaging. We are unable to serve homemade products. Illness and Medication For your child’s well-being and the protection of other children, please keep your child at home with any symptoms. Children who are not feeling well cannot fully participate in activities planned at the center. For your child’s well-being and the protection of other children, keep your child at home when he/she has ANY of the following symptoms: Vomiting Diarrhea Severe cold, including persistent running/snotty nose Persistent chest cough Auxiliary (underarm) temperature of 100 degrees (without adding a degree) Undiagnosed rash Earache Sore throat or difficulty swallowing Difficulty breathing or wheezing Child does not feel well enough to participate in the normal daily activities Temperature of 100 degrees or more Conjunctivitis /Pink eye Lice If your child has any of these symptoms while at home, we ask that they are kept at home until symptom free (WITHOUT medication) for 48 hours. If your child becomes ill while attending the Center, he/she will be isolated from the other children. He/she will be supervised, and the parent will be called. Parents are asked to pick up their child within one hour. Parents need to have alternative child care arrangements for ill children. I will notify the Center Manager if my child has been ill or exposed to a contagious disease. I understand that my child cannot attend if she/he has a fever, rash, or other condition that prevents him/her from participating in Center activities. Children need to be symptom free without the aid of fever reducers for 48 hours. I understand that I will be notified if my child becomes ill or has an accident while at the Center. If my child has an accident, immediate first aid will be given but further treatment will be the responsibility of the parent. I will be notified of any significant occurrences or problems which affect my child, potentially including exposure to a communicable disease, head lice, etc. from children or Center staff. Notify the center director if your child needs to take any medication during hours of operation. Non-prescription medications can be given, providing a parent/guardian submits parent authorization. Discipline The goal of Early Childhood Alliance program is to provide a positive environment in which children can succeed. We accomplish this with redirection, problem-solving and conflict resolution. In cases of continued negative behavior, a plan of action will be created with parents and staff. Discipline means learning. It does not mean punishment, tears, or humiliation. It means a chance to learn how to live in a social world. Discipline is not something adults do to their children; it is something they do with their children. The goals of discipline are self-control and responsibility. Teachers and parents are most likely to achieve these goals when they respond to the causes of behavior, as well as to the behaviors themselves. The teachers of the Center silently observe a child’s behavior before reacting and responding to them. Teachers may use a variety of discipline techniques to meet the needs of different situations, including: Let children make some decisions and choices. One good way to teach responsibility is to give the child the opportunity to make choices. Give reasons for rules. Understanding the reasons for rules makes it easier to remember and follow them. Be consistent in language and behavioral response to children. Adults’ consistent behavior helps the development of inner control through modeling. Remove children from situations they can’t handle. If a child is too young to understand or there is no way to change the cause, it may be possible to change the situation. Redirect the child’s behavior. Often there is a way to let children do something in a better place or a safer way. Let children learn the consequences of their actions when appropriate. Recognize and encourage positive behavior. Allow children to participate in the problem solving process when discipline issues occur. I understand that if my child cannot adjust to the program because of social, physical or emotional problems, after a reasonable trial period and/or plan of action, the agency will help in making an appropriate referral or placement, and I will find other care for my child. Miscellaneous Your child’s file must be complete with all required forms and updated regularly to assure the health and safety of your child. Consent* I have read and understand the parent orientation itemsBy checking the box above you are indicating that you have read the above parent orientation statements and understand them all.