Location Address Number Belvidere 2229 Anderson Dr. (847) x 1913

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9 STATE OF ILLINOIS DEPARTMENT OF HUMAN SERVICES CERTIFICATE OF CHILD HEALTH EXAMINATION FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 5/2006 Please Print Student s Name Last First Middle Birth Date Sex Grade Level ID# Parent/ Telephone # Address Street City ZIP code Guardian Home Work IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication. VACCINE/DOSE Diphtheria, Tetanus and Pertussis (DTP or DTaP) Diphtheria and Tetanus (Pediatric DT or Td) Inactivated Polio (IPV) Oral Polio (OPV) Haemophilus influenzae type b (Hib) 1 MO DA YR 2 MO DA YR 3 MO DA YR 4 MO DA YR 5 MO DA YR 6 MO DA YR Hepatitis B (HB) Varicella (Chickenpox) Comments Combined Measles, Mumps and Rubella (MMR) Measles (Rubeola) Rubella (3-day measles) Mumps Pneumococcal (not required for school entry) PCV7 PPV23 PCV7 PPV23 PCV7 PPV23 PCV7 PPV23 PCV7 PPV23 PCV7 PPV23 Check specific type (PCV7, PPV23) Date Other (Specify hepatitis A, meningococcal, etc.) Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. Signature Title Date Signature (If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Title Date Signature (If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Title Date ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) *MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR Physician s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below is verifying that the parent/guardian s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title Date 3. Laboratory confirmation (check one) Measles Mumps Rubella Hepatitis B Varicella Lab Results Date MO DA YR (Attach copy of lab report, if available.) VISION AND HEARING SCREENING DATA Date Age/Grade Vision Hearing IL (R-01-05) Pre-school annually beginning at age 3; School age during school year at required grade levels R L R L R L R L R L R L R L R L R L R L Printed by Authority of the State of Illinois (Complete Both Sides) Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/ Contacts

10 Student s Name Birth Date Sex School Grade Level/ ID # Last First Middle Month/Day/ Year HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER ALLERGIES (Food, drug, insect, other) MEDICATION (List all prescribed or taken on a regular basis.) Diagnosis of asthma? Child wakes during the night coughing? Yes Yes No No Indicate Severity Loss of function of one of paired organs? (eye/ear/kidney/testicle) Yes No Hospitalizations? When? What for? Yes No Birth complications/prematurity? Yes No Developmental delay? Yes No Blood disorders? Hemophilia, Surgery? (List all.) Yes No Sickle Cell, Other? Explain. When? What for? Yes No Diabetes? Yes No Serious injury or illness? Yes No Head injury/concussion/passed out? Yes No TB skin test positive (past/present)? Yes* No Seizures? What are they like? Yes No TB disease (past or present)? Yes* No Heart problem/shortness of breath? Yes No Tobacco use (type, frequency)? Yes No Heart murmur/high blood pressure? Yes No Alcohol/Drug use? Yes No Dizziness or chest pain with Family history of sudden death Yes No exercise? before age 50? (Cause?) Yes No Eye/Vision problems? Glasses Contacts Last exam by eye doctor Dental Braces Bridge Plate Other Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) Other concerns? *If yes, refer to local health department. Ear/Hearing problems? Yes No Bone/Joint problem/injury/scoliosis? Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Signature Date Entire section below to be completed by MD/DO/APN/PA PHYSICAL EXAMINATION REQUIREMENTS HEAD CIRCUMFERENCE HEIGHT WEIGHT BMI B/P DIABETES SCREENING (Not required for daycare.) BMI 85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No LEAD RISK QUESTIONAIRRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. Questionairre Administered? Yes No Blood Test Indicated? Yes No Blood Test Date Blood Test Result. (If child resides in Chicago, blood test is required.) TB SKIN TEST Recommended only for children in high-risk groups including children who are immunosuppressed due to HIV infection or other conditions, recent immigrants from high prevalence countries, or those exposed to adults in high-risk categories. See CDC guidelines. No Test Needed Test performed Date Read / / Result mm LAB TESTS (Recommended) Date Results Date Results Hemoglobin or Hematocrit Sickle Cell (when indicated) Urinalysis Developmental Screening SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs Skin Endocrine Ears Eyes Normal Yes No Objective screening Yes No Result Gastrointestinal Genito-Urinary Amblyopia Yes No Referred to Opthalmologist/Optometrist Yes No Neurological Nose Musculoskeletal Throat Spinal examination Mouth/Dental Nutritional status Cardiovascular/HTN Respiratory Mental Health NEEDS/MODIFICATIONS required in the school setting DIETARY Needs/Restrictions LMP SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student s health with school or school health personnel, check title: Nurse Teacher Counselor Principal EMERGENCY ACTION needed while at school due to child s health condition (e.g.,seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes No If yes, please describe. On the basis of the examination on this day, I approve this child s participation in (If No or Modified,please attach explanation.) PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS (for one year) Yes No Limited Physician/Advanced Practice Nurse/Physician Assistant performing examination Print Name Signature Date Address Phone (Complete both sides)

11 LOCATION ADDRESS HOSPITAL Belvidere 2229 Anderson Dr. St Anthony Medical Center Specialized Infant & Toddler Care Emergency Form Page 10

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13 Safari Childcare, Inc 2013 Page 12

14 Safari Childcare, Inc 2013 Page 13

15 SAFARI CHILDCARE TUITION AND POLICIES SHEET Child s Name: Age Birth Date Policies 1. Tuition must be paid every week regardless of the number of days the child attends. This includes time missed due to illness, weather, vacation, national holiday, or any other reason. (Safari is closed New Year s Day, Memorial Day, 4 th of July, Labor Day, Thanksgiving and Christmas Day). 2. The multi-child discount is $10 per child per week. 3. Full day childcare rates allow up to 9 hours of care per day. Extended care hours are available at a rate of $5.00 per hour. 4. All tuition calculations will be rounded to the nearest dollar. Promotions may only be used for new customers. 5. Cash, Money Order, or Tuition Express from Credit/Debit Card must be used to pay all tuition. A $30 NSF Fee will be charged if the automatic withdrawal is declined. 6. In the event of disenrollment, any over payment and/or security deposit on your account will be refunded within (30) days upon your written request at (under the "contact us" tab). Pre-Enrollment 1. Registration Fee & Security Deposit must be paid in full by cash, money order or Tuition Express automatic withdrawal prior to start. 2. Registration Fee: $100 per child or $150 per family, Registration Fees are Non-Refundable. 3. Security Deposit per child: 1-Week of tuition. Security Deposit may be raised if a child s attendance increases or if tuition is not paid on time. The security deposit cannot be used to cover shortages in weekly tuition. Extended Care, Night Care or Weekend Care 1. Tuition for hours before 6:30am, after 6:30pm and Weekends: (Infant-$10.00) (Toddler-$9.50) (Two-$8.50) (Three to Twelve $7.00) Safari Prep/Safari Academy/Summer Camp/4-to-1 Ratio Childcare 1. Safari Prep AM class is from 9am-12:00pm, Safari Prep PM class is from 1:00pm-4:00pm. 2. Safari Academy is only available for children from ages 2-5 years old who attend Monday Friday from 8:00am-5:00pm. Extended care beyond these hours is available at a rate of $5.00 per hour. 3. Summer Camp hours are from 8:00am-5:00pm. Extended care beyond these hours are available at a rate of $5.00 per hour. 4. Safari s 4-to-1 ratio room is only for pre-screened students between the ages of 2 and 5. A parent on subsided care whose child qualifies for the 4:1 room would be required to pay the difference between what the state pays and what the 4:1 room charges. Public Assistance Customers (With current approval) 1. Safari only accepts Public Assistance customers with 5 full day approvals. 2. Weekly Co-Pay in the amount of must be paid each week regardless of attendance. 3. For Co-Pay only, a child may attend from 7:00am-12:00pm or 1:00pm-6pm and participate in the Safari Prep AM/PM program. 4. For Co-Pay plus $25.00 per week, a child may participate in any of our childcare classrooms (see Policies, #3 above). 5. For Co-Pay plus $80.00 per week, a child may participate in the Safari Academy (See Safari Prep/Safari Academy #2 & #3). 6. Children must attend 80% of their eligible days approved or they will be dis-enrolled. This is computed based on your eligible days per month which varies by month. Payment Procedure 1. A "Safari Week" accrues tuition from Saturday until the following Friday each week. At the end of each "Safari Week" Safari will (or provide a paper copy at your request) a weekly bill by Sunday at 1pm. Children cannot attend Monday without full payment at the time of drop off on Monday. If payment is not receive by Monday at 5pm a 20% late fee (not less than $25) will be charged for all outstanding tuition and immediate dis-enrollment will occur. An additional 20% charge will be added weekly to all outstanding balances. Other Fees 1. $10.00 no sign-in fee per child/per occurrence is charged for any family that does not clock their child in and/or out on both the time clock and sign in/out sheets. 2. $1.00 per minute/per child is charged for pick-ups after the school's official closing time. Charges will begin at 6:35pm. 3. Additional charges may occur for special events such as field trip or in-house events; you will be notified in advance. 4. Each family will receive (2) key fobs for use to enter the school. Upon disenrollment key fobs must be returned or a $10 fee will be assessed to your account for each key fob.

16 Disclaimer We reserve the right to make any changes to these policies or tuition with (1) week notice. We also reserve the right to make any decision when a particular situation does not clearly fall into one of the policies. Failure to abide by Safari Childcare, Inc. tuition and policies may result in immediate disenrollment. Enrollment is contingent upon each family s ability to abide by Safari Childcare Inc. s policies and procedures. This includes demonstrating reasonable behavior within the center and adherence to laws and regulations that guide us. Failure to abide by these policies/procedures will result in immediate disenrollment. Thanks for taking the time to read Safari Childcare's tuition and policies. Please let us know if you have any questions. Revised 3/1/14 Safari Childcare, Inc. Please select: 1 day 2 days 3 days 4 days 5 days Days/Times Attending: to to to to to Monday Tuesday Wednesday Thursday Friday Program Selection: Safari Childcare: Infant Toddler Two Year Old Three to Five Six to Twelve Before and/or After Kindergarten Safari Prep: AM session (9:00-12:00) PM session (1:00-4:00) Safari Academy Summer Camp (4-12 year olds) Extended Care, Night Care, or Weekend Care 4:1 Ratio Room Public Assistance: AM session (7:00-12:00) PM session (1:00-6:00) Copay + $25 Copay + $80 Registration Fee Total: Security Deposit Total: Weekly rates: Child 1 Child 2 Child 3 Child 4 Name: Name: Name: Name: Person responsible for tuition and other fees must print & sign below verifying they have read and understand Safari Childcare s tuition policies and agree to abide by them. (Print and Sign) Date Internal Use Only: School Location: Program Director Name (Print): Date District Manager Signature: Date

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