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Children’s Land at Wheeling
Learning Center
Registration File
850 McHenry Rd.
Wheeling, IL 60090
phone: 847 537-3340
fax: 847 537-3341
e-mail: www.childrensland.us
0BRegistration Form
5BChild Information
Child’s Name ______Birth Date ______Gender ______
Address ______
City ______Zip Code ______
Starting Date ______Ending Date ______
42BParents / Legal Guardians Information
Father’s Name / Mother's Name
Home Phone # / Home Phone #
SSN# / SSN#
Home Address / Home Address
Occupation / Occupation
Employer / Employer
Work Address: / Work Address:
Working Hours / Working Hours
Business Phone # / Business Phone #
Cell Phone # / Cell Phone #
E-Mail / E-Mail
Marital Status: Married-----Separated-----Divorced----Widowed------Single Parent
35BSchedule
To enable us to prepare staff and plan accordingly, please place a check in front of the appropriate schedule and the appropriate days.
1. ____Full Time ______Monday
2. ____Part Time ______Tuesday
______Wednesday
______Thursday
______Friday
Child’s Physician Information:
Name: ______
Address: ______
Phone#: ______
38B
Parent(s)/Guardian(s) Signature: ______39BDate: ______
Emergency Card
6BChild’s Name ______
/7BGroup Age ______
/8BBirth date______
/9BAddress______
/10BCity ______Zip______
/11BParent(s)/Guardian(s):
/12BName______
/13BName______
14BWork# ______
/15BWork# ______
16BHome# ______
/17BHome# ______
18BMobile/Beeper# ______
/19BMobile/Beeper# ______
Relative or Friend Alternate: ______
1.______Phone______
2.______Phone______
Pediatrician______Phone______
Allergies------Last DPT------
Medications______Hospital______
Other Significant Medical Info______
______
I hereby give permission to the medical personnel selected by Children’s Land, Inc to order x-ray, routine tests and treatment for my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Children’s Land, Inc to hospitalize, secure proper treatment for, and to order injections and/or anesthesia and/or surgery for my child.
I hereby give my permission for the Children’s Land, Inc to contact my pediatrician for any information needed about my child, and to authorize my pediatrician to release such information to Children’s Land, Inc.
Signature Parent/Guardian:______
Date:______
37BMedical Consent
I, ______, as parent/guardian of ______, hereby authorize The Children’s Land, Inc by and through its officers, agents, or employees to remove the above minor child from its premises for the purpose of obtaining emergency medical treatment if the need so arises. I further agree that The Children’s Land, Inc is hereby authorized to procure whatever emergency medical treatment that may be necessary, either through a duly licensed physician, dentist and/or a duly accredited hospital or clinic. It is also understood that I will hold The Children’s Land, Inc harmless for the nature, performance, and outcome of any such emergency medical treatment and that the determination of whether and emergency has arisen within the terms of this agreement shall be left to the sole discretion of The Children’s Land, Inc.
Parent/Guardian______
Date ______
Emergency Contacts:
I, ______, as parent/guardian of______, hereby authorize Children’s Land, Inc staff in case of emergency, to contact people listed below if I cannot be reached:
Name:Relationship:
Phone #:
Address:
Name:
Relationship:
Phone #:
Address:
Name:
Relationship:
Phone #:
Address:
Name:
Relationship:
Phone #:
Address:
Name:
Relationship:
Phone #:
Address:
Name:
Relationship:
Phone #:
Address:
Signature Parent/Guardian:______Date ______
Family Profile Form
Have there been any recent family changes (if yes, please check and list date):
20BO Moves______
/21BO New Job______
22BO New Hours______
/23BO New Baby ______
24BO Serious Illness______
/25BO Change in Caregiver ______
26BO Family Death______
/27BO Loss of Pet______
28BO Other Loss______
/29BO Other______
What was child told about family changes? ______
______
How did she/he react? ______
Does your child have any specific fears? ______
1BChild’s Health/Medical Information
30BChild’s Physician ______
/31BChild’s Dentist ______
32BPhone ______
/33BPhone ______
40BHospital Affiliation ______
36BGeneral Health: Where or are there any physical or medical factors of which we should be aware?
34BO Allergies______
O Vision______
O Hearing______
O Eating Difficulties______
O Ear infections How often? Fluid? O Yes O No
Does your child take medication regularly? O Yes O No
Describe______
Any special instructions? ------
Has your child ever experienced: (Give type/reason and date)
O Serious Illness Type/Reason______Date______
O Hospitalization Type/Reason______Date______
O Operation Type/Reason______Date______
O Accident Type/Reason______Date______
O Injuries Type/Reason______Date______
2BOther
Are there any aspects of your child’s development that are of concern to you?______
______
Does your child have specific fears?______
Is there any other information you would like to provide?______
______
Are there any other professionals working with your child or family?______
Do you feel that collaboration would be useful? O Yes O No
41BParent/Guardian Signature______
HELP US TO KNOW YOUR CHILD BETTER
3BChild’s name ______Date ______
1. Does Your Child Have any Allergies?
2. What Foods Does Your Child Like?
3. What Foods Does Your Child Dislike?
4. Does Your Child Have Any Special Fears?
5. How Do You Discipline Your Child?
6. Has Your Child Ever Been In A Pre-School / Day Care Setting Before?
7. Is There Anything Else We Should Know About That Affects Your Child?
8. Is Your Child Potty Trained?
9. If Yes, At What Age?
10. By What Name Do You Call Your Child At Home?
11. What Can Your Child Do For Him/Herself (Dress, Chores, Etc…)
12. Does Your Child Have Other Scheduled Activities Besides School?
13. If Your Child Has Siblings, How Do They Relate To Each Other?
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Dear Parents:
1. Children cannot come to school if they are less than 24 hours free of vomiting, diarrhea and fever.
2. Children cannot come to school with heavy discharge from noses, pink eye, and any kind of rash on the body.
3. Children, who come to school with symptoms listed above, will be sent home.
4. Medication, both prescription and non‐ prescription, will be accepted only in its original container.
a) Prescription medication shall be labeled with the full pharmacy label. Medication will be administered as required by a physician, subject to the receipt of appropriate releases from parents (Administer Medicine form).
b) Over‐the‐counter (non‐prescription) medication shall be clearly labeled with child’s first and last name.
The container shall be in such condition that the name of the medication and the directions for use is clearly readable. It will be administered in accordance with manufacturer’s instructions when provided by the parents with written permission (Administer Medicine form).
Children, who come to school with symptoms listed above, will be sent home.
Parent Signature ______Date ______
Children’s Land at Wheeling
List Of Persons Authorized To Pick Up The Child Regularly
I, ______, as parent/guardian of ______, hereby authorize people listed below to pick up my child:
Name:Relationship:
Phone #:
Address:
Name:
Relationship:
Phone #:
Address:
Name:
Relationship:
Phone #:
Address:
Name:
Relationship:
Phone #:
Address:
Name:
Relationship:
Phone #:
Address:
Arrival And Departure Policy
Children’s Land at Wheeling Learning Center, Inc day care center is open Monday through Friday from 6:30AM to 6:30 PM. Parents are responsible for the safe arrival of their child and must bring their child in the classroom area to the staff. Children may not enter the building unattended. When picking up children, parents will receive them from the staff. Parents are expected to observe the 6:30 PM closing time. The late pick up fee will be applied to your monthly bill: $10.00 for every 10 minutes that you are late. At that hour, staff members are eager to resume their personal lives after a very busy day. If your child is to be picked up by someone other than yourself or other authorized person, we must have a note stating with whom the child is to go. Under no circumstances will a child be releases to a person who has not been authorized. This is for your child’s safety. Persons not known to the staff may be required to provide a driver’s license or some other type of photo identification to establish their identity.
Parent(s)/Guardian(s) Signature:______Date: ______
Permission Form For Athletic Activities and Dancing
I agree to my child’s participation in any school athletic activities such as but not limited to running, playing games, using outdoor and indoor athletic equipment. This will also include up to 1 hour as much as three times a week of an aerobic/dancing exercise session. In consideration for any reasonable precaution being taken by the school staff to ensure the safety and well – being of the child. I hold employees and officers harmless of any potential injuries or claims.
I hereby give my permission to administer first aid to my child. In case of emergency, the Children’s Land, Inc staff will promptly contact the paramedics to treat and transport my child to the nearest hospital, then attempt to contact the parent(s).
I hereby give permission to the hospital’s selected physician to administer emergency services. In case of an emergency and I cannot be reached, you may contact:
Parent Name: ______
Child’s Name: ______
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4BProgram Permission Form
1. I give permission for my child ______To receive appropriate medical attention from Children’s Land staff, such as First Aid, CPR, Heimlich maneuver, etc., or, it is determined that my child needs immediate professional medical care, I authorize Children’s Land to transport him or her to the nearest emergency hospital. Parents will be contacted immediately. I understand that I will be responsible for all of his/her expenses in relation to emergency medical services.
2. I hereby give permission for Children’s Land staff to contact my Pediatrician for any information needed about my child. I authorize my pediatrician to release such information to Children’s Land, Inc.
3. I understand that I am legally responsible for my child while he or she is on route to and from Children’s Land programs.
Parent’s Signature ______Date______
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Permission Form For Photos, Film, Videos, and Field Trip
I agree to my child’s participation in any school photo taking, film, and videos. In consideration for any reasonable precaution being taken by the school staff to ensure the safety and well – being of the child. I hold employees and officers harmless of any potential injuries or claims.
During a field trip I hereby give my permission to administer first aid to my child. In case of emergency, the Children’s Land, Inc staff will promptly contact the paramedics to treat and transport my child to the nearest hospital, then attempt to contact the parent(s).
I hereby give permission to the hospital’s selected physician to administer emergency services. In case of an emergency and I cannot be reached, you may contact:
Parent Signature:______Date______
Child’s Name: ______
Photographs & Publicity Policy
We periodically take pictures of the children in the center to let parents know and see what is going on during the day. Children are at the center for long hours and this is one way that we can allow parents be a part of their child's day.
Ø Pictures are placed on the bulletin boards located in the hallways of the center.
Ø Pictures are placed in the child's portfolios, located in the classroom.
Ø Pictures are used and placed throughout the classroom.
Ø Pictures are used as part of art projects.
Ø Pictures are used as a form of observation and evaluation of the child.
Extra pictures are always given to the child's parents/guardians.
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IMPORTANT INFORMATION
On your child’s first day of attendance, your child will need the following items:
1. Change of Clothing – pants, shirt, underclothes and socks. Please make sure that your child’s change of clothes are always weather appropriate.
2. Small pillow for nap time – We provide and wash the cot sheets and blankets weekly. If you would like to have your child’s pillow and blanket washed, please let your child’s teacher and they can leave it out on Fridays. Please make sure that you bring them back on Monday morning. The center does not keep extra pillows or blankets.
3. Diapers and wipes if your child is not potty trained.
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COPY OF BIRTH CERTIFICATE
Dear Parent/Guardian,
Per state law a copy of your child’s birth certificate is needed for enrollment to our childcare center.
Thank you,
Director
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PARENT-PROVIDER CHILD CARE CONTRACT
1. The following contract is between:
Mother/legal guardian ______
Father/legal guardian ______
School name ______
for the care of:______
Child’s name and birth date
Starting date of this contract______Ending date of this contract ______
2. Standard Rates and Payment Policies:
Registration fees - $25.00 (Not refundable. Does not apply as discount or part of payment to any other fees).
The parent/guardian who applies for financial assistance will have to co-pay the difference between the provider’s weekly charges and the financial assistance from Action for Children. In case a parent decides to terminate the contract, provider must get a 2 week written notice. If parent/guardian will fail to provide the termination notice, provider will report parent/guardian to collection agency with payment due, for the period of time that child was absent plus the two weeks.
43BPayment is due [ ] weekly [ ] monthly
The provider will provide:
Breakfast, Morning snack, Lunch , Afternoon snack
The parent / guardian will provide diapers, wipes, and change of clothes.
Parent / guardian must supply a current medical form, completed by the child’s doctor and updated every other year.
3. Rates for holidays, absences, vacations, overtime:
Care will not be provided, but payment is due, on the following holidays when they occur on a day the child(ren) is/are regularly scheduled for care:
New Year day
Memorial Day
Independence Day
Labor Day
Thanksgiving Day
Christmas day
In case if provider will not receive weekly payment on time, a $10.00 per day late fee will be charged in addition to your next weekly payment. Payment invoices will be mailed to the parent/guardian household on weekly/monthly basis.