Dreamers Child Care Enrollment Application Child s Full Name Gender Birth Date Address Home Phone Chronic Physical Problems / Pertinent Developmental Information / Special Accommodations Needed Previous Day Care Programs / Schools Attended PARENTS/GUARDIANS Father Name of Employer Business Phone Cell Phone Father s Home Address (if Different from Above) Father's Email Address Mother Name of Employer Business Phone Cell Phone Mother s Home Address (if Different from Above) Mother's Email Address Person(s) or Agency Having Legal Custody (If other than Parent)
EMERGENCY INFORMATION Allergies / Intolerances to Food / Medication Please note action to take in case of emergency Name of Child s Physician Phone 1. _ Name Address Phone Number 2. Name Address Phone Number Additional Person(s) Authorized to Pick Up Child **Person(s) NOT Authorized to Pick Up Child (please provide appropriate documents) Child s Physician or Clinic: Telephone: Address:
Program (Please Select): Infant (6 weeks - 15 months) Toddler (15 months - 33 months) Pre-School (3 years - 4 years) Pre-Kindergarten (4 years - first day of school) School-Age (5 years - 12 years) (Please Select): Fill Fill Fill
AGREEMENTS Please read and initial the following agreements. 1. Dreamers Child Care agrees to notify the Parent/Guardian if child becomes ill while at center. Parent/Guardian agrees to pick-up, or arrange for pickup as soon as possible if requested by Dreamers Child Care staff. 2. Parent/Guardian authorizes Dreamers Child Care to obtain immediate medical care if an emergency occurs and Parent/Guardian cannot be located immediately. This authorization is not required by State Regulation if the parent raises and/or states any objection to provision of such care on religious or other such grounds. 3. Dreamers Child Care herein states that tuition is charged at a fixed monthly rate. No reductions will be permitted, unless provided by tuition assistance programs, including but not limited to: number of school days in a given month, number of days a child attends, vacation/holiday, etc. 4. Parent/Guardian has read, understood and agrees to be bound by and adhere to ALL terms and conditions set for the in the parent handbook. 5. Dreamers Child Care reserves the right to deny, sever, cancel or suspend a child's enrollment at any time, if deemed in the best interest of Dreamers Child Care. 6. Dreamers Child Care herein reserves the right to update, change, or alter this document in any way it deems in its best interest. Such updates will take place, without automatic notification to parents. SIGNATURES Parent / Guardian Date Center Administrator Date **CENTER USE ONLY** Place of Birth Date of Birth Birth Certificate Number Date Admitted Date Withdrawn Date Registration Free Paid Initial Monthly Tuition Out of Pocket CCAP Assistance Co-Pay Tuition Due Date Full
Emergency Medical Authorization Form Child s Name Date of Birth Parent / Guardian Name Home Address Home Phone Father s Place of Employment Work Phone / Cell Phone Mother s Place of Employment Work Phone / Cell Phone Parent/Guardian authorize Dreamers Child Care to obtain immediate care and consents to the hospitalization and/or the performance of necessary diagnostic tests or the use of surgery on, and/or the administration of drugs to his/her child if an emergency occurs when he/she cannot be located immediately. It is also understood that this agreement covers only those situations which are true emergencies and only when he/she cannot be reached. Otherwise he/she expects to be notified immediately. Signature of Parent/Guardian Date 2. Medical treatment costs are covered by: A. Insurance Policy Name Member ID Group # B. Secondary Insurance (if any): Member ID Group # C. No Insurance Coverage Signature of Parent/Guardian Date
AUTHORIZATION TO ADMINISTER MEDICATION CHILD CARE CENTERS MEDICATION INFORMATION AND AUTHORIZATION A. FACILITY AND CHILD INFORMATION Name Child Care Center Name Child Birthdate (mm/dd/yyyy) B. MEDICATION INFORMATION: Medication shall be in the original container and labeled with the child s name. The label shall include dosage and directions for administration. Time(s) of Day to be How to be Dates Medication Time Period Name Medication Dosage Administered Administered From To AM AM AM AM PM PM PM PM Yes No Does the over-the-counter (OTC) medication label indicate the child s physician should be consulted? If Yes I have consulted with my child s physician, and I am authorizing a dosage consistent with the physician s recommendation. Name OTC Medication Parent Initials Additional information / special instructions / contraindications Specify. C. AUTHORIZATION I hereby authorize administration of the above medication to my child by staff of the child care center listed above. SIGNATURE Parent or Guardian Date Signed
Please Sign and Return this page to Dreamers Child Care office staff. Thank You. By signing below, I affirm that I have read and reviewed in its entirety, the Parent Handbook document, and agree to consent fully and wholly. I understand and appreciate the fact that I will be bound to follow and conduct myself by ALL the terms and conditions put forth in the document. Seen and agreed: Signature of Parent / Guardian Date
Dreamers Child Care LLC Health Care Summary (To be completed by health care provider) Enrollment Date: Child's Name: Birth Date: Height (Percentile): Weight (Percentile): Address: Phone Number: Physical Findings (N = NORMAL; AB = ABNORMAL) Area: N/AB: Comments: Area: N/AB: Comments: 1. Head 11. Cardiovascular 2. Face 12. Abdomen 3. Neck 13. Genitals 4. Eyes 14. Extremities 5. Ears 15. Joints 6. Nose 16. Muscle Tone 7. Mouth 17. Skin 8. Throat 18. Neurological 9. Chest 19. VISION 10. Spine 20. HEARING Lab Findings: Hemoglobin/Hematocrit: Urinalysis: Sickle Cell: Blood Lead: Mantoux: Other: 1. Assessments: 2. Does this child have ALLERGIES? ٱ No ٱ Yes Specify: Recommendations: 3. Is there a condition which may result in an emergency: ٱ No ٱ Yes Specify: Emergency Plan: 4. Important Health Problems: Followed By (Name & Title): Special Care Needed In Childcare Program: 5. Is this child developing appropriately for his/her age? ٱ Yes ٱ No If not, what modifications in the Childcare Program are needed: 6. Nutrition: Is a special diet necessary: ٱ No ٱ Yes Type of formula: Until what age? Milk (Whole, 2%, etc.): Age for introduction of solid foods: Meat Fruit Eggs Orange Juice Cereal Vegetables Table Foods How Long Have You Been Seeing This Child: Name Of Clinic, If Applicable: Address: Telephone Number: Signature of Health Care Provider: Date Of Exam: Date Form Completed:
Name Birthdate Date of Enrollment Minnesota law requires children enrolled in child care to be immunized against certain diseases or file a legal medical or conscientious exemption. Parent/Guardian: You may attach a copy of the child s immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or laboratory evidence of immunity and CO for vaccines that are contrary to parent or guardian s conscientiously held beliefs. Sign or obtain appropriate signatures on reverse. Complete section 1A or 1B to certify immunization status and section 2A to document medical exemptions (including a history of varicella disease) and 2B to document a conscientious exemption. For updated copies of your child s vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 800-657-3970. Type of Vaccine Child Care Immunization Form Must be on file before a child attends child care DO NOT USE ( ) or ( ) 1st Dose Mo/Day/Yr 2nd Dose Mo/Day/Yr 3rd Dose Mo/Day/Yr 4th Dose Mo/Day/Yr 5th Dose Mo/Day/Yr Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please write the date in the shaded box.) Diphtheria, Tetanus, and Pertussis (DTaP, DTP) 3 doses during 1st year (at 2-month intervals) 4 th dose at 12-18 months 5 th dose at 4-6 years Indicate vaccine type: DTaP or DTP Polio (IPV, OPV) 2 doses in the first year 3 rd dose by 18 months 4 th dose at 4-6 years Measles, Mumps, and Rubella (MMR) Required for children 15 months and older 1 st dose on or after 1 st birthday 2 nd dose at 4-6 years Haemophilus influenzae type b (Hib) 2-3 doses in the first year 1 dose required after 12 months or older For unvaccinated children 15-59 months, 1 dose is required Not required for children 5 years or older Varicella (chickenpox) Required for children 15 months and older 1 st dose on or after 1 st birthday 2 nd dose at 4-6 years Pneumococcal Conjugate Vaccine (PCV) Required for children age 2-24 months 3 doses in the first year 4 th dose after 12 months At least 1 dose is recommended for children 24-59 months in child care Hepatitis B (hep B) 2-3 doses in the first year 3rd dose (final dose) by 18 months Hepatitis A (hep A) 2 doses separated by 6 months for children 12 months and older Recommended Rotavirus (2-3 doses between 2 and 6 months) 4th dose not required if 3rd dose was given on or after the 4th birthday 5th dose not required if 4th dose was given on or after the 4th birthday Influenza (annually for children 6 months or older) Developed by the Minnesota Department of Health - Immunization Program www.health.state.mn.us/immunize (12/13)
Instructions, please complete: Box 1 to certify the child s immunization status Box 2 to file an exemption (medical or concientious) Name 1. Certify Immunization Status. Complete A or B to indicate child s immunization status. A. Children who are 15 months or older: For children who are 15 months or older and who have received all the immunizations required by law for child care: I certify that the above-named child is at least 15 months of age and has completed the immunizations which are required by law for child care. B. Children who are younger than 15 months: For children who are younger than 15 months OR have not received all required immunizations: I certify that the above-named child has received the immunizations indicated. In order to remain enrolled this child must receive all required vaccines within 18 months from initial enrollment date. The dates on which the remaining doses are to be given are: Signature of Parent / Guardian OR Physician / Nurse Practitioner / Physician Assistant / Public Clinic Date Signature of Physician / Nurse Practitioner / Physician Assistant / Public Clinic Date 2. Exemptions to Immunization Law. Complete A and/or B to indicate type of exemption. A. Medical exemption: No child is required to receive an immunization if they have a medical contraindication, history of disease, or laboratory evidence of immunity. For a child to receive a medical exemption, a physician, nurse practitioner, or physician assistant must sign this statement: I certify the immunization(s) listed below are contraindicated for medical reasons, laboratory evidence of immunity, or that adequate immunity exists due to a history of disease that was laboratory confirmed (for varicella disease see * below). List exempted immunization(s): Signature of physician / nurse practitioner / physician assistant Date *History of varicella disease only. In the case of varicella disease, it was medically diagnosed or adequately described to me by the parent to indicate past varicella infection in (year) B. Conscientious exemption: No child is required to have an immunization that is contrary to the conscientiously held beliefs of his/her parent or guardian. However, not following vaccine recommendations may endanger the health or life of the child or others they come in contact with. In a disease outbreak, children who are not vaccinated may be excluded in order to protect them and others. To receive an exemption to vaccination, a parent or legal guardian must complete and sign the following statement and have it notarized: I certify by notarization that it is contrary to my conscientiously held beliefs for my child to receive the following vaccine(s): Signature of parent or legal guardian Date Subscribed and sworn to before me this: day of 20 Signature of physician / nurse practitioner / physician assistant (If disease occured before September 2010, a parent can sign.) Signature of notary (A copy of the notarized statement will be forwarded to the commissioner of health.) Developed by the Minnesota Department of Health - Immunization Program www.health.state.mn.us/immunize (12/13)