Whittier Kids Child Enrollment Form 2017-18 School Year Child s Full Name: Birthdate: Nickname/Preferred Name: Gender: School Age Program Preschool Program Grade 2017-18 School Year: Parent/Guardian Name: Address: City: Zip: Primary Phone: Other Phone: Employer: Work Phone: Email: Please use this email for program emails and billing. Initial here to give permission to share above Name, Primary Phone and Email for internal class rosters. (Preschool families) Parent/Guardian Name: Address: City: Zip: Primary Phone: Other Phone: Employer: Work Phone: Email: Please use this email for program emails and billing. Initial here to give permission to share above Name, Primary Phone and Email for internal class rosters. (Preschool families) If parents are not at the same address, correspondence should be addressed to: If tuition is shared by two parties, what is the arrangement: Are there any custody arrangements Child resides with: (check all that apply) Mother Father Both Parents together Foster parents Mother/Stepfather Father/Stepmother Grandparent(s) Parent s Significant Other Mother/Mother Father/Father Other: Other: Siblings in Household: Name: Age: Name: Age: Name: Age: Name: Age: Name: Age: Name: Age: Does your family qualify for child care subsidies from any of the following? State of Washington (DSHS) City of Seattle Subsidy Other: If yes, please provide attach a copy of your approval letter.
Local Emergency Contacts Name: Primary Phone: Home Address: Relation to Child: Name: Primary Phone: Home Address: Relation to Child: Out of Area Emergency Contact Name: Primary Phone: Home Address: Relation to Child: Authorized Pick Up Individuals (other than parents/guardians) authorized to pick-up your child. (Please note that authorized pick-up individuals must be 12 or older. Please be advised that all authorized pick-up individuals must show photo identification and be listed on this form in order to pick-up your child. This is a precautionary measure to ensure the safety of your child.) 1. Name: Primary Phone: Home Address: Relation to Child: 2. Name: Primary Phone: Home Address: Relation to Child: 3. Name: Primary Phone: Home Address: Relation to Child: Signature: Parent/Legal Guardian Signature: :
CHILD HEALTH INFORMATION Does your child have any allergies? (foods, medicines, etc). YES Does your child have any of the following (please check all that apply): Frequent colds/ear infections Skin Disorders (i.e. rashes) Asthma Diabetes Heart Trouble Stomach Upsets Frequent Constipation Urinary Difficulties Frequent Diarrhea NO If yes, we will provide an Allergy Packet to be submitted to provide complete details. Please note these forms require a physician s signature. Briefly describe the allergy Does your child have an intolerance? YES NO If yes, briefly describe the intolerance *Allergy vs. Intolerance: A food allergy causes an immune system reaction that affects numerous organs in the body. It can cause a range of symptoms. In some cases, an allergic reaction to a NONE Febrile Seizures Fainting Spells Other Please provide details of any items marked above: Has your child been diagnosed with any of the following (please check any that apply): NONE Language Delay ADD/ADHD Vision Impairment Autism or Related Disorder Hearing Impairment Behavioral/Emotional Disorders Learning Disability Developmental Delays Mental Illness Other Other Other Please provide details of any items marked above: LIST OF CHILD S BEHAVIORS (please check all that apply): NONE Difficulty with transitions Has a hard time in groups Difficulty in controlling anger Prefers to play alone Fearful and anxious Loses temper Argues with parents or teachers Touchy, easily annoyed by others Sensitive to criticism Trouble sitting still, fidgety Other Other Please provide details of any items marked above:
Statement of Authorization: Medical Treatment, Field Trips, Hand Sanitizer, Photographs, Sunscreen Medical Treatment: I hereby give permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a qualified staff member of Whittier Kids. In the event I can not be contacted, I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I further consent to the disclosure of health information and to the medical, surgical and hospital care treatment and procedures (including, but not limited to, administration of necessary anesthetics, tests, x-ray examinations, transfusions, injections, drugs) to be performed for my child by a licensed physician or hospital selected by Whittier Kids director when deemed immediately necessary or advisable by the physician to safeguard my child s health. Field Trips: I give permission for my child to participate in field trips with Whittier Kids. I understand that transportation will be via school bus, Metro bus, or by foot. I understand that I will be notified in advance of all scheduled field trips. I understand that the utmost caution will be used to provide for my child s safety. I consent, and agree to hold harmless the PNA, its Board of Directors, employees and agents from liability in case of unforeseen events while on a field trip. Hand Sanitizer: Yes I give permission for my child to use hand sanitizer while at Whittier Kids while on a field trip or when soap and water are not available. State licensing requirements permit child care facilities to give hand sanitizer to children only with the written consent from the parent/guardian when on field trips and when soap and water are not available. Hand sanitizer is not meant to replace regular hand washing practices of soap and water. No Please do not use hand sanitizer for my child while on a field trip or when soap and water are not available. Photographs: Whittier Kids/Phinney Neighborhood Association (PNA) has my permission to use pictures of my child participating in Whittier Kids activities: Yes or No Internal use: Classroom and school bulletin boards, art displays and Whittier Kids Newsletter (emailed to WK families only) Yes or No External use: Whittier Kids/PNA website, marketing purposes (flyers/posters) and PNA s quarterly magazine, The Review Sunscreen: Please apply sunscreen to your child before dropping them off in the morning. Yes No I give permission for Whittier Kids to apply Rocky Mountain Sunscreen to my child (ingredients listed below). State licensing requirements permit child care facilities to apply sunscreen to children only with the written consent from the parent/guardian. Please sign below f you would like your child to use our sunscreen when needed. Ingredients: Avobenzone 3.0, Homosalate 10%, Octisalate 5%, Octocrylene 2%, Oxybenzone 2.5%. Other Information: SPF 30, broad Spectrum UVA/UVB, hypoallergenic, fragrance free, very water resistant, 80 minutes. Please use a different sunscreen which we will provide in a ziplock bag labeled with our child s name and fill out a separate authorization form (we will email to you or you can find on our website). Due to licensing requirements, if we do not have this signed form on file and you check this box we will not be able to apply sunscreen to your child at Whittier Kids. Please use the following sunscreen which I will provide for my child: Your signature below acknowledges receipt of and agreement to the information provided above: Parent/guardian signature: :
CONSENT FOR EMERGENCY TREATMENT As the parent/guardian, I hereby give consent to Whittier Kids that my child,, maybe given emergency treatment to include First Aid/CPR by a qualified staff member of Whittier Kids or Medic. I also give permission for my child to be transported by an aid car, ambulance or staff car to the nearest medical treatment center or hospital, if necessary. As parent/legal guardian, I authorized a qualified physician to examine the above-named child and in the event of injury to administer emergency care and to arrange for any consultation by a specialist, including surgeon and/or dentist, as deemed necessary to insure proper care of any injury for my child. I understand that every effort will be made to contact parents/guardian to explain the nature of the problem prior to any involved treatment. It is understood that a conscientious effort will be made to notify me or other persons listed on this form before such action is taken. In the event it becomes necessary for Whittier Kids staff-in-charge to obtain emergency care for your child, neither the staff-in-charge nor Whittier Kids assumes financial liability for expenses incurred because of accident, injury, illness, and/or unforeseen circumstances. Parent/guardian Signature: : Complete each section of this form in its entirety: Child s Physician: Last exam date: Phone: Address: Child s Dentist: Last exam date: Phone: Address: Insurance: Policy #: Allergies/Reaction: Parent/guardian Name: Phone: Home Address: Parent/guardian: Phone: Home Address: Phone: Local Emergency Contact: Phone: Address:
HEALTH & WELL-BEING AGREEMENT: Per State of Washington child care licensing and public health requirements, the following is available for parents to review at any time. These documents are posted in the parent area in each classroom and copies are available. Please take the time to read and understand these documents. Center Health Policy: Center policy and procedures relating to staff and child health practices, communicable disease exposure and reporting, medication and first-aid management and other healthrelated topics. Pesticide Policy: Center policy adhering to public health standards and in partnership with the schools where each center is located. Disaster Preparedness Policy: Center policy in partnership with the schools where the center is located. Covers policy for major natural disaster preparedness, staff responsibility and disaster supply management. Pet Policy: Center policy and procedures for the caring of classroom pets. Covers types of pets that are allowed/not allowed and certain procedures for caring for some pets. I understand that the above documents are available for review. Parent/guardian signature: : Parent/Guardian Contract: As a parent or legal guardian, I have read and agree to following statements: I grant permission for Whittier Kids to provide care for my child. I have read the Whittier Kids Family Handbook and agree to its policies (available on our website). I understand that changes to my child s schedule must be received by the 15th of the month in order to change billing for the next month and that Whittier Kids requires 30 days notice to withdraw completely from our program. I understand that changes and withdrawals are subject to the policies outlined in the Whittier Kids Family Handbook (available on our website). I realize it is my responsibility to keep Whittier Kids informed of any changes in emergency contact information. I agree to update information in my child s file as changes occur. I have received a current fee schedule and agree to pay the charges for my child s care as outlined in the fee schedule. I understand that monthly tuition is due in full on or before the fifth of each month (or next business day). Tuition is divided into 10 equal monthly payments and no credits are issued for absences/vacations. Parent/Legal Guardian Signature: : Updated 2/2017
Certificate of Immunization Status (CIS) For Kindergarten-12 th Grade / Child Care Entry Office Use Only: Reviewed by: : Signed Cert. of Exemption on file? Yes No Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System. Child s Last Name: First Name: Middle Initial: Birthdate (): Sex: I give permission to my child s school to share immunization information with the Immunization Information System to help the school maintain my child s school record. Parent/Guardian Signature Required I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required Required for School and Child Care/Preschool Required Only for Child Care/Preschool DTaP / DT (Diphtheria, Tetanus, Pertussis) Tdap (Tetanus, Diphtheria, Pertussis) Required Vaccines for School or Child Care Entry Documentation of Disease Immunity Healthcare provider use only If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider Td (Tetanus, Diphtheria) I certify that the child named on this CIS has: Hepatitis B 2-dose schedule used between ages 11-15 a verified history of Varicella (Chickenpox). Hib (Haemophilus influenzae type b) IPV / OPV (Polio) laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s) for titers MUST also be attached. MMR (Measles, Mumps, Rubella) PCV / PPSV (Pneumococcal) Varicella (Chickenpox) History of disease verified by IIS Recommended Vaccines (Not Required for School or Child Care Entry) Diphtheria Mumps Other: Hepatitis A Polio Hepatitis B Rubella Hib Measles Tetanus Varicella Flu (Influenza) Hepatitis A HPV (Human Papillomavirus) MCV / MPSV (Meningococcal) MenB (Meningococcal) Rotavirus Licensed healthcare provider signature (MD, DO, ND, PA, ARNP) Printed Name
Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand. To print with immunization information filled in: Ask if your healthcare provider s office enters immunizations into the WA Immunization Information System (Washington s statewide database). If they do, ask them to print the CIS from the IIS and your child s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at https://wa.myir.net. If your provider doesn t use the IIS, email or call the Department of Health to get a copy of your child s CIS: waiisrecords@doh.wa.gov or 1-866- 397-0337. To fill out the form by hand: #1 Print your child s name, birthdate, sex, and sign your name where indicated on page one. #2 Vaccine information: Write the date of each vaccine dose received in the date columns (as ). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. #3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements. If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section. #4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS. Reference guide for vaccine abbreviations in alphabetical order Full Vaccine Full Vaccine Abbreviations Abbreviations Name Name DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 DTaP DTP Flu (IIV) HBIG Diphtheria, Tetanus, acellular Pertussis Diphtheria, Tetanus, Pertussis Influenza Hepatitis B Immune Globulin Reference guide for vaccine trade names in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine ActHIB Hib Fluarix Flu Havrix Hep A Menveo Meningococcal Rotarix Rotavirus (RV1) Adacel Tdap Flucelvax Flu Hiberix Hib Pediarix For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Full Vaccine Full Vaccine Abbreviations Abbreviations Abbreviations Full Vaccine Name Name Name Meningococcal Conjugate Vaccine Hep B Hepatitis B MenB Meningococcal B Hib HPV (2vHPV / 4vHPV / 9vHPV) IPV Haemophilus influenzae type b Human Papillomavirus Inactivated Poliovirus Vaccine MPSV / MPSV4 DTaP + Hep B + IPV RotaTeq Afluria Flu FluLaval Flu HibTITER Hib PedvaxHIB Hib Tenivac Td Bexsero MenB FluMist Flu Ipol IPV Pentacel DTaP + Hib + IPV Trumenba MenB Rotavirus (RV5) Boostrix Tdap Fluvirin Flu Infanrix DTaP Pneumovax PPSV Twinrix Hep A + Hep B Cervarix 2vHPV Fluzone Flu Kinrix DTaP + IPV Prevnar PCV Vaqta Hep A Daptacel DTaP Gardasil 4vHPV Menactra MCV or MCV4 ProQuad MMR + Varicella Varivax Varicella Engerix-B Hep B Gardasil 9 9vHPV Menomune MPSV4 Recombivax HB Hep B MMR MMRV Meningococcal Polysaccharide Vaccine Measles, Mumps, Rubella Measles, Mumps, Rubella with Varicella If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-013 December 2016 OPV PCV / PCV7 / PCV13 PPSV / PPV23 Oral Poliovirus Vaccine Pneumococcal Conjugate Vaccine Pneumococcal Polysaccharide Vaccine Rota (RV1 / RV5) Rotavirus Td Tetanus, Diphtheria Tdap VAR / VZV Tetanus, Diphtheria, acellular Pertussis Varicella