FORM 1: BACKGROUND AND HEALTH INFORMATION
Pleaseprint clearly
Child'sfullname: _
Whatdoesyourchildprefertobecalled? _
GENERALINFORMATION
Thefollowinginformationwillhelptheteachersupportyourchild'sadjustmenttotheprogramme.
Briefdescriptionofyourchild'spersonality(e.g.,shy,confident,quiet,tentative)
Toys/activitiesyourchildespeciallyenjoys:
Eatinghabits(likes/dislikes):
Toiletroutine(trained,intheprocess,notready): _
Developmentalaccomplishments(fillinapproximateage):
Crawling
_ Walking
Talking:singleword)
_ ShortSentences _
Specificfearsoranxieties(e.g.,dogs,darkness,confinement):
Previousexperiencebeingawayfrom parent(if any):
Friendswhowillbeinschoolwith yourchild:
Namesandagesof siblings:
Pets(typeandnames):
Holidaysyoucelebrateathome(e.g.,Christmas,Chanukah,Kwanzaa):
Otherpertinentinformation:
HEALTHINFORMATION
Pleasedetailallallergiesto anydrug,serum,food,environment,animal,plant,etc.:
List,withadate,anypastillnesses,operations,accidentsorcommunicablediseases(e.g.,chicken
pox):
Doesyourchild wearglasses,contactlenses,ahearingaid,braces,etc?
Isyourchildtakinganyregularmedication?Pleasespecify:
Isyourchildseeingaspecialist?Ifyes,pleaseprovidedetails:
Isthereanyotherhealthinformationthestaffshouldknowaboutinordertobesthelpyourchild
(e.g.,frequentcolds,speechconcerns,behaviourpatterns)?Pleasedescribe:
Parent/GuardianSignature:
Date:
(day/month/year)
FORM 2: EMERGENCY CONTACTINFORMATION
Dateofadmission:
Dateofwithdrawal:
CHILD'S INFORMATION(This form is filed in a separate binder. Please complete in full.)
Child'sFullName: _
BirthDate:
(day/month/year)
Allergies:
OtherHealthConcerns:
HealthCardNumber:
(Include version code)
Doctor’sname:
Address:
Telephone:
EMERGENCYCONTACT(incaseparents/caregivercannotbereached)
Pleaseprovide oneTorontocontact
Contact#1Fullname: _
Relationship: _
HomeAddress(complete in full):
Postal Code:
Home #: Cell #:
Email:
Please indicate the best way to contact this person during school hours: ______
PARENTS/LEGAL GUARDIAN INFORMATION(completeIN FULL)
Parent1Fullname:
HomeAddress(Where child resides):
Postal Code:
Home #: Cell #:
Email:
Please indicate the best way to contact you during school hours: ______
FullWorkAddress:
Street Suite
______
City PostalCode
Parent2Fullname:
HomeAddress(if different from above):
Postal Code:
Home #: Cell #:
Email:
Please indicate the best way to contact this person during school hours: ______
FullWorkAddress:
Street Suite
______
City Postal Code
CAREGIVERINFORMATION
Fullname:
HomeTelephone: _
CellPhone: _
AUTHORIZED RELEASE
Mychildonlycanbereleasedtothefollowingpeople:
FullName: _
Relationship: _
FullName: _
Relationship: _
FullName: _
Relationship: _
FullName: _
Relationship: _
FullName: _
Relationship: _
FullName: _
Relationship: _
FORM 3: CONSENTAND WAIVERFORM
1. SCHOOLOUTINGPERMISSIONSLIP
Iunderstandthattheschoolorganizesschooloutings(typicallytwo or three peryear)andwillnotify meinadvanceofallexcursions.Ialsoacknowledgethatifmy childisunabletoattenda field trip/excursion, he/shewill have tostayathomeastheschoolisnotopen.Accordingly,I authorize mychild(namedbelow) togoonanytripsscheduledaspart ofthesupervisedactivitiesofOriole NurserySchool,whilehe/sheisenrolledintheschool,andmaybetransportedasarrangedbythe schoolofficersandstaff.
2. MEDICALCONSENT
Iunderstandthatintheeventofanemergency,adoctormay havetotreatmy childwhenthe parents/guardianscannotbecontacted.Iunderstandeveryeffortwillbemadetoreachthe
parents/guardians.If,atanytime,medicaltreatmentis necessaryduetosuchcircumstancesasan accident,suddenIllness,oremergency,Iauthorizethatthistreatmentmay begiventomychild.I understandthatanyexpenseincurredforsuchtreatmentismyresponsibility.
3. WAIVER
IwaiveandreleaseOrioleNurserySchoolanditsrepresentativesfromany andallclaims,
demands,actions,orcauses ofactionwhichmayariseoutofaccident,illness,injury,ordamage which mayoccurto thebelownamedchildorhis/herpropertywhile participatingintheschool
activitiesandonandoff siteexcursions.Ialsoassumeandacceptallrisk,danger,hazardsinconnectionwithOrioleNurserySchool.
4. FINANCIALOBLIGATIONS
I confirm that I have read and clearly understand the fee schedule and refund policy as
listed on the web site and provided to me in correspondence.
5. FORMS
Iagree tosubmitcompletedimmunizationandallotherrequired forms priortomychildstarting school.Should the schoolnotreceive theseforms,mychild maynotattenduntiltheyaresubmit- ted.
6. PHOTORELEASE
I agreetolet mychildtobephotographedwiththeunderstandingthat thesephotographsmaybe usedtopromotetheschool,primarilyonourschoolbrochureorWebsite.Iunderstandthechildren willnotbenamedoridentifiedinanyway.
7. CONTACTINFORMATION
Iagreethattheschoolcanforwardmy contactinformationtootherfamiliesandstaffwithinthe Oriole NurserySchool community.Iagree notto use thisinformation outside ofschool-related activities,includingbutnotlimitedtopromotingmybusinessorother non-school-relatedpersonal interests.
8. HANDSANITIZER
Iauthorizemychild(namedbelow)to usehandsanitizeronpicnics,fieldtripsand occasionally in theclassroom.
9.WalkingTrips
Iauthorizemychild (namedbelow)toparticipate inwalking tripsplannedbytheschool,toneigh- bourhoodvenuessuch asthe dentist,the grocerystore etcasthese tripssupportourunitsof study.IunderstandthatIwillbenotifiedinadvanceofanytripsthatwill takeplace,andthatmy participationmayberequired.
Pleaseprintclearly
Child'sFullName:
Ihaveread,understoodandagreedtoalloftheaboveitems.
Parent/GuardianSignature: _
Parent/GuardianSignature:
FORM 4: IMMUNIZATION INFORMATION
Request forImmunization Information for NewRegistrants of Day
Nurseries
Instructions for Parents/Guardians
Pleasehelpuskeepchildreninlicensedchildcareprogramshealthybymakingsureyourchildis properlyimmunized.Youarerequiredtoprovideanup-to-daterecordofyourchild's iimmunization toyourLicensedChildCareProvider.
TorontoMedicalOfficerofHealthrecommendsthatallchildrenwhoattenddaycareare immunized accordingtotherevisedPubliclyFundedImmunizationScheduleforOntario-August2011. Thisschedulecanbefoundat
Aparent orguardianofachild registeringina licensedchildcareprogram mustprovide oneofthefollowingtotheLicensedChildCare Provider.
Anup-to-daterecordof theirchild'simmunization.
OR
A medical exemptionform,completedbyaqualified medical practitionerwhichclearly statesthemedical reasonswhythechildcannotbeimmunized.
OR
Anotarized letterprovidedinwritingobjecting totheimmunizationon thegroundsthatit conflictswith aparent/guardian’sconscienceor religiousbeliefs.
Ifanoutbreakoccurs,anychildwhoisnotadequatelyimmunizedwillnotbeabletoattendthe childcarefacilityuntilthechildreceivestherequiredvaccineoruntiltheoutbreakisdeclared over.
Instructions:
1.Completethefollowingpageofthisformandreturnitwithyourregistrationpackage.
2.Fillinthedatesofeachneedle(year/month/day),orattachaclearphotocopyofthechild's immunizationrecord.Bothsidesoftherecordmustbeincluded.
3.Ifyoudonothaveanimmunizationrecordforyourchild,takethisformtoyourdoctor.
4.WhenyourchildreceivesanotherneedlegiveacopyofthisinformationtotheLicensedChild
CareProvider.
5.IfyoudonothaveanOntarioHealthCardcall416-392-1250.Youwillreceiveinformation aboutwhereyourchildcanreceivefreeimmunizationservices.
Child’sname:
VaccineDatesgiven
(D/M/Y) / Diphtheria / Pertussis / Tetanus / Polio / Haemophilus B (HIB) / Pneumococcal / Rotavirus / Meningococcal-C / Meningococcal-ACYW / Measles / Mumps / Rubella / Varicella
(Chickenpox) / Hepatitis B / Influenza / Otherimmunizations,testresults or comments
Physician’sSignature:
Physician’sAddress:
TelephoneNo. ( )
Date:
CalltheTorontoPublic HealthImmunizationInfolineat416-392-1250toaskany questionsaboutimmunization
Duty Day Participant Information
Parents, caregivers and extended family members are welcome to participate in bi-weekly ‘Duty Days’. Being a Duty Day participant means that you are trained as an assistant teacher and counted towards our adult to child ratio- it’s a very important job!
Participants are required to:
1. Attend a 2 hour training/Orientation workshop (offered monthly, beginning in September)
2. Submit completed immunization form(see below)
3. Submit a Vulnerable Sector Police Reference Check (Oriole will provide one form per family. Additional forms are available at a cost of $20)
4. Submit a Standard First Aid and CPR-C certificate (from a WSIB certified service provider.)
Please note: ALL of the above information must be submitted priorto your family’s fist Duty Day. The Ministry of Education and Public Health standards prohibit a person from working or volunteering with children (as counted towards ‘ratio’) unless the above information is on file.
If, at any time, you are unable to make your scheduled duty day, you may:
a) Switch with another parent
b) Hire an on-call assistant ($65 per day, payable to Oriole Nursery School. A list of assistants will be provided at the Orientation.)
For a full description of Duty Day participant responsibilities, refer to the Parent Handbook (“Duty Day Procedures and Daily Routines.”)
Duty Day participants are considered staff members and are included in our adult to child ratio. A fine of $200 will be levied onto any participant who does not show up for their Duty Day (and who has not attempted to switch with another parent, hire an assistant or inform the Supervisor of their difficulty to do so before 8:30am.) Should a second ‘no show’ occur, the family shall be required to switch to a non-participating status, and to pay the necessary fees associated with the switch.
I ______understand the above policy and agree to the terms outlined.
(printed name)
______
(Signature) (Date)
We thank you for your understanding in this matter and look forward to your participation in the classroom!
FORM 5: IMMUNIZATIONTUBERCULOSIS SCREENINGINFORMATION
ForAll Persons Working and Volunteering in Licensed ChildCarePrograms
Under the Child Care and Early Years Act, Section 57(1), "Every licensee of a child care centre shall ensure that, before commencing employment, each person employed…has a health assessment and immunization as recommended by the local medical officer of health".
Toronto Public Health requires all employees to have up-to-date immunization as listed below. Students and volunteers are also recommended to receive these vaccines. (Duty Day participants are considered “employees” because they count towards the mandated adult to child ratio.
Vaccine / Recommendations for staff, students & volunteersHepatitis B / o All staff should be vaccinated. Children with hepatitis B may not show
symptoms and hepatitis B status may not be known.
Influenza / o Annually, especially for those who care for children under 5 years of age
Measles
Mumps / o 2 documented doses of MMR vaccine or proof of immunity
Rubella
Diphtheria / o 1 dose of Tdap in adulthood -This can replace the next scheduled dose of Td
Tetanus / o Tetanus and diphtheria (Td) vaccine booster every 10 years
Pertussis
Varicella / o 2 doses of chickenpox vaccine given at least 6 weeks apart or proof of
immunity. Previous immunity can be determined by a self-reported history of
chickenpox or a blood test.
Immunization Exemptions
If you have a valid exemption for medical, religious or philosophical reasons this will be kept in your file. (Philosophical and religious exemptions require a notarized form. This can be round on the Ministry of Education’s website.) If the disease appears in the child care centre, you may have to stay out of childcare until the outbreak is declared over to minimize the risk of spreading the disease.
Tuberculosis Screening
Toronto Public Health requires all employees to provide documented TB testing prior to employment. The TB skin test should be done anytime within 6 months before the start of employment. For employment purposes, you may have to pay for the TB skin test. If the TB skin test is negative, no further testing is needed.
If the TB skin test is positive, a medical examination and chest x-ray are required. The physician should provide documentation that you are free of TB disease before beginning work.
Please have your health care provider complete the other side of this form and return it to the Child Care Centre supervisor before commencing employment.
Immunization and Tuberculin Screening for all persons working in Child Care Centres
Employee Name
LAST NAMEMIDDLE NAMEFIRST NAME
Date of Birth
(year/month/day)
Home Address
NUMBERSTREET NAMEUNIT#CITYPOSTAL CODE
Emergency Contact
LAST NAMEFIRST NAME
Telephone Number
HOMEBUSINESS
Most recent dates for required immunization
Vaccine / Date / Date / DateTdap
Td
MMR
Varicella
Hepatitis B
Influenza
Tuberculosis Screening
Tuberculin Skin Test / Date given / Date read / Induration size / Interpetation
(mm) / (pos/neg)
Chest x-ray (if required) / Date / Result
If the result is positive, consider LTBI treatment and visit , then click on "Information for Health Professionals".
Personal health information on this form is collected under the authority of the Health Protection and Promotion Act, R.S.O. 1990, c.h.7. It is used to administer the Toronto Public Health Vaccine Preventable Diseases Program, including maintaining immunization records for Child Care Centres. The confidentiality of this information is protected. For more information, visit our Privacy Statement at tph.to/personalhealthinfoor contact Manager, Vaccine Preventable Diseases – 235 Danforth Ave., 2nd floor or by telephone at 416-392-1250.
FORM 6: SCHEDULING AND DUTYDAY INFORMATION
***AllparentsandcaregiversparticipatinginDutyDaysmustcompletethisform***
Each"participating"familyisexpectedtoattend bi-weeklyDutydays,perchild. Allparticipatingfamilies, newandreturning,arerequiredto attendthetwo-hourDutyDayOrientation, offeredmonthly (with some exceptions.)The Orientationhighlightstheroutine,new policies, health and safety requirements and behaviour management expectations.Ifyouoradditionalduty day participantsareunabletoattendthefirst Orientation offered,youwillbeaskedtopay for a replacement ($65 per Duty Day missed), and are welcome to attend the next scheduled workshop. Pleasereferto the Parent Handbookfordetailsrelatingto DutyDayresponsibilitiesandtheschedulingprocess.
Child'sFirstandLastName:
Child'sclass(Pleasecircle) Junior Senior
Pleasecirclethedaysyouwillbe AVAILABLEfordutydays.Wewillmakeeveryefforttomeetevery- one'sneedswhenscheduling.(Please indicate at least 3 days.)
Monday Tuesday Wednesday Thursday Friday
PleaseindicatewhowillbeattendingonDutyDays.EachpersonidentifiedasaDuty Day participantmustcompleteaPoliceReferenceCheck Form, (MAILEDSEPARATELY) a completed immunization form, a valid Standard First Aid and CPR-C certificate, and attendaDutyDayOrientation. (Please note: Oriole Nursery School will pay the cost of one police reference check form per child. Additional duty day participants are required to submit $20.00 for each subsequent form.)
FullNameofDutyDayParticipant:
RelationshiptoChild:
FullnameofAlternateDutyDayParticipant: _
Relationshipto Child:
FullnameofAlternateDutyDayParticipant: _
Relationshipto Child: