Little Blessingsof Anoka Early Childhood Learning Center

Appendix G

Little Blessingsof Anoka Early Childhood Learning Center

Information Form

Child’s Name: ______Nickname: ______

Date of Birth: ______Male ____ Female ____

Address: ______

StreetCityZip

______

Father’s Name: ______Phone: ______

Address: ______

StreetCityZip

Cell Phone: ______Work Phone: ______

E-mail address: ______

Place of Employment: ______

______

Mother’s Name: ______Phone: ______

Address: ______

StreetCityZip

Cell Phone: ______Work Phone: ______

E-mail address: ______

Place of Employment: ______

______

Who will bring your child to school? ______Approx. arrival time: ______

*Who will pick up child from school? ______Approx. pick up time: ______

***Under NO circumstances should ______be allowed to take my child from the center.

*** If parents are living in separate households, parent with custody must provide court documentation of why other parent is not permitted to pick up.

Over

The welfare of your child is our first consideration. In case of medical emergency or illness, an ambulance form Mercy Hospital will be called immediately. Then the parent or guardian will be called. The name of your physician as well as the name of the parent or guardian will be given to the ambulance attendant. In case of a minor emergency, the center will contact the parent or guardian at work or at home immediately. If you cannot be reached, we will call emergency contacts as listed on the Child Information Card and they have permission to make necessary decisions to treat my child.

Physician Name: ______Phone: ______

Address: ______

StreetCityZip

Dentist Name: ______Phone: ______

Address: ______

StreetCityZip

List any allergies your child has to foods or medication: ______

______

(An Individualized Child Care Plan [ICCP] must be provided by doctor in case of allergies. Must be renewed yearly.)

Tell us about any health concerns you have regarding your child: ______

(An Individualized Child Care Plan [ICCP] must be provided by doctor in case of asthma or eczema. Must be renewed yearly.)

Family Information

Are both parents in the home with the child? Yes / No

Other children in the home:

Name: ______Age: ______
Name: ______Age: ______
Name: ______Age: ______
Name: ______Age: ______

If both parents are not in the home, what does your child know about the situation and how does he/she accept it? ______

Other adults who live in the home and relationship to your child: ______

Is your child adopted? Yes / No At what age did you adopt him/her? ______Have they been told? Yes / No

Is there any other family information you can share with us that will help us to better care for your child? ______

Social Development

Has your child had previous group experience and if so, where? ______

How does your child get along with other children? ______

Social approach (circle all that apply): Shy / Friendly / Cautious / Outgoing

Please share any information that would be helpful to us in regard to his/her social behavior: ______

Emotional Behavior

Characteristic behavior (circle all that apply): Calm / Excitable / Easily angered / Easy going / Fearful / Outgoing / Independent / Gives in easily / Wants own way / Cooperative

What behaviors do you consider the most difficult to deal with, if any?

______

Types of discipline used at home by mom: ______

By dad: ______

Eating Habits

Does your child have any food allergies: Yes / No If yes, please list: ______

Favorite Foods: ______Dislikes: ______

Any information you would like to share with us regarding your child’s eating habits? ______

Appendix G

PERMISSION SLIP FOR ______

(child’s name)

Please read the following permission requests and initial on lines provided, then sign/date at the bottom of the page.

The following list is not provided by the center, but I will provide when asked.

I give my permission for Little Blessings of Anoka Early Childhood Learning Center to use the following items:

Non-Aerosol Sun Screen ______Diaper Ointment ______Anti-bacterial hand wipes ______

Anti-bacterial hand wipes ______Baby/diaper wipes ______Non-Aerosol Bug spray______

Fragrance-free hand lotion ______Vaseline (for chapped lips) ______

Walk/Park Permission

I give permission for my child to go for walks around the neighborhood with staff from Little Blessings of Anoka Early Childhood Learning Center. ______

Photo Permission

I give my child permission to have his/her picture taken while participating in Learning Center activities to use for promotions such as brochures, bulletin boards in the center, Little Blessings of Anoka’s website and for community awareness such as newspaper articles. ______

Facebook Policy

I give permission to have my child’s picture, in which they are engaged in center activities, posted on Little Blessings of Anoka’s Facebook page. I understand my child’s name will not be printed under the picture by the staff of LBoA. _____

Handbook Policy

I/We have read the Parent Handbook Policy and understand and agree to abide by the policies and procedures as stated in it. I also understand that from time to time the Center’s governing board (Anoka Community Missions Board of Directors) and/or Center Director may implement or change policies as needed and I will be notified of such changes. ______

Sick Policy

I/We have read the Sick Policy which I/we understand and agree to abide by the policy. _____

______

Parent’s SignatureDate