Consent
to Emergency First Aid & Transportation hereby give permission that my child, ____________________, may be given emergency
treatment by a staff member at Little Angels Family Daycare . I also give permission for my child to be transported by car,
ambulance, or other means to an emergency center for treatment, if necessary.
Parent’s Signature: ______________________________
Date: ____________________Consent to Medical Care and Treatment
In the event that I cannot be contacted immediately,
medical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician,
and holding Susan Tabishesky and its employees harmless.
I understand this is a legally binding contract and I have
read if and understand it.
Parent/ Guardian (Mother):________________ Parent/Guardian (Father): ____________
Parent’s
Signature: ___________________________ Date: _______________________
Last Name: ________________ First Name: _____________
Nick Name: ___________
Birth Date: _________________ Place of Birth: ___________ Age: _________________
Brother(s)
__________________ Age: ______ Sister(s) _______________ Age: _____
Please circle the appropriate response:
Is
child able to feed self? Yes No
Child eats Slowly Quickly
General appetite is Good Poor
Child likes: ______________________________________________________________
Child
dislikes: ___________________________________________________________Food allergies: ___________________________________________________________
Special
needs: ____________________________________________________________
SLEEPING Usual bedtime: ___________________ Time
child wakes up: ____________________
Sleeps through night? Yes No
Does child wet the bed? Yes No
If yes,
how often? _________________________________
Is the child accustomed to a nap? Yes No
If yes, for what duration
of time? _________________________________
Can child dress self? Yes No
Manage buttons? Yes No
Manage zippers
Yes No
In what areas does the child need help? ________________________________________
Does child tell an adult
that he/she needs to Yes No
use the bathroom?
What expressions does the child use to tell an adult that he/she
needs to use the bathroom?
At what age was the child:
Walking: __________ Talking: __________ Toilet trained:
____________
The primary language spoken at home: ________________________________________
Is child’s speech
clear to others? Yes No
Does child bite nails? Yes No
Does child suck thumb? Yes No
Does child have particular
fears or habits? _____________________
Does child have strong temper? Yes No
Chief play interest: ________________________________________________________
Favorite
toys: ___________________ Favorite play area at home: _________________
Does child play alone or with others? (list
ages of others): _________________________
Does child play well with other children? ______________________________________
Is
it hard for child to share? _________________________________________________
Has the child had other group experiences
(preschool, daycare, etc.)? ________________ ________________________________________________________________________
Provide
name of other programs child has attended: ______________________________
Any other important information about child:
Enrollment Contract
Child’s
Name: ________________________ Start Date:_________________________
I/we, as parent(s) or guardian, enroll or re-enter
our child(ren) at Little Angels Family daycare with the understanding of the following:
To secure a space for your child
at Little Angels , a non-refundable registration fee of $50.00 is required, And all of the paperwork is to completely filled
out . With a copy of your child’s shot records
Any late departures, after closing time, are subject to a $1.00
per minute late fee. In the event that a child is left for longer than an hour after closing, the staff will make every attempt
to contact the identified emergency contacts until it is necessary to contact the proper authorities as mandated by DCYF.
Days/Hours: Monday _____ Tuesday _______ Wednesday ______ Thursday______ Friday ______
The tuition fee for child
care services will be $ ___________ per week, based on ___________ Days & hours per week. Reimbursement will not be made
when your child(ren) is late, dismissed early or absent.
Weekly tuition payment is due on Friday of the each week that
your child is in care. For every family with more than one child attending , there will be a 10% discount off one child’s
weekly tuition. Please include your child’s name and the weeks(s) you are paying for in the memo section of your check.
Little Angels Family Daycare automatically adds a $15.00 late fee for each Day that you are late in making tuition payments.
Accounts that are (1) or more weeks in arrears are subject to termination.
Please Call me by 8:00a.m. or sooner if
your child will not be in care , If you do not You will still have to pay for that day that your child did not come.
Please
make Checks Payable to Susan Tabishesky .
There will be a $35.00 charge for returned checks.
Little Angels Family
Daycare reserves the right to raise rates at any time.
To maintain proper staff/child ratio, agreed upon dates and times
on the contract can not be altered unless A change form or A staff member has been Notified in writing and another contract
must be completed, signed and dated. If space is available, extra child care services may be arranged for an additional fee.
If
any change in parent agreement is necessary, please contact the My self ASAP, Examples: Emergency person, address, telephone
number, times, medical information. etc.
When Little Angels Family daycare is closed for a holiday, the weekly tuition
payments will remain the same. Note: part-time enrollees, if your child is scheduled to attend on a holiday another day can
be substituted.
Little Angels Family daycare will close when a State of Emergency is declared, inclement weather conditions
or unforeseen circumstances arise . Tuition payment will remain the same.
When Susan Tabishesky is informed of a planned
vacation 2 weeks prior to anticipated absence, the parent is allowed a 50% discount for that weeks tuition. The 50% discount
can be utilized for one vacation week each year and only after 6 months of full or part-time enrollment.
Please give
2 weeks notice if your child will no longer be coming to my daycare . if you take your child(ren) out before you give notice
or they do not come . You are still responsible for tuition for that 2 weeks .
Parent/Guardian Signature
Date Susan Tabishesky Date
____________________________________________ ____________________________
Parents
Social Security # _________________
This Contract is good until your child goes
to school or until services are not needed or from 1 year .
Medication Permission Form
Name of child: ___________________________________________________________
Name of medication: ______________________________________________________
Prescription: _____________________ Non-Prescription: ________________
Dosage: ________________________________________________________________
Date(s) medication to be given: ______________________________________________
Times medication to be given: _______________________________________________
Reasons for medication: ____________________________________________________
Possible side effects: ______________________________________________________
Name and phone number of prescribing physician:
Directions for storage: _____________________________________________________
I, ___________________________________________________,
(parent or guardian)
give permission
to authorize staff member (s) to administer medication to my child as
indicated above.
Parent/Guardian Signature Date
Doctor’s Signature:
______________________________________________________
(needed
for non-prescription medication)
** ALL medication is to be brought in by an adult and must be picked up by an adult
as well.
** Children are not allowed to transport nor have medication in their possession.
** ALL medication must
have child’s name & dosage clearly marked and be in the original bottle
** Only one medication per form
**
Nebulizer treatments require a physician’s note
Little Angels Family Daycare
Susan Tabishesky
Warwick, Rhode Island
02886
(401) 738-9747
Family Name: _____________________ Family Name: __________________
Child’s
Name: _____________________ Child’s Name: _________________
Phone: ___________________________ Phone: _______________________
*If
parents refer a family and they enroll, the referring family will be given tuition credit , of
$50.00
Child’s Name: ________________________________________________________
I give permission for my child to be photographed or filmed for media use and publicity in conjunction with
Little Angels Family daycare /Susan Tabishesky
YES NO
I give permission to take photographs of my child and to
use them on bulletin boards and to identify each child’s cubby (if needed).
YES NO
________________ ___________________________
Date
Parent’s/Guardian Signature
