Enrolment Package

1

Application for Enrolment Alternate Emergency Contacts Emergency Medical Treatment Consent Health Information Authorized Release Person(s)

1 1 1 2 3

Developmental History 4 Permission to Take Part in Field Trips 9 Publicity Consent

Parent Contract

9

10

APPLICATION FOR ENROLMENT Admission date Child’s Name

Discharge date

Date of Birth (dd/mm/yyyy) Home address

Parent/Guardian 1 Name

Home address

Phone Number Work Address

Cell

Work Phone number

Parent/Guardian 2 Name

Home address

Phone Number Work Address

Cell

Work Phone number

Alternate Emergency Contacts

(To be called in the event that the parents/guardian’s cannot be reached) Name:

Address

Phone Number(s) Name:

Address

Relationship to child

Relationship to child

Phone Number(s) Family Physician Name

Address

Phone number

Emergency Medical Treatment Consent

In the event of illness or accident involving my child and every effort has been made to reach us and if neither parent/guardian nor alternates can be reached, I hereby authorize the administration of any medical procedures deemed necessary by the child’s physician or Hospital Emergency Staff. I also give permission to Guelph Outdoor Preschool staff to transport my child to the Emergency Department of the hospital. Yes_ No_ Signature of Parent/Guardian Date:

1

In the event of your child receiving emergency medical treatment, does the attending physician need to be aware of your child having: a) any allergies?

b) any specific medical conditions?

Health Information:

Does your child have any suspected or confirmed life-threatening allergies? Yes*_ No_

*If yes, please see supervisor to complete an Individual Anaphylaxis Emergency plan form

*If an epinephrine auto-injector is to be used, please fill out the appropriate authorization Form as well. If your child is (or has ever been) under treatment or supervision for a health problem,(physical, emotional, vision, hearing, speech or chronic illness such as asthma) please provide details:

If your child had any communicable disease, ( such as Chicken Pox, Pertussis), please describe:

Has your child ever had any serious illness, accident or operation?

Has your child ever experienced a cessation of breathing?

Should there be any restrictions to your child’s activities, diet or rest? Yes_ No_

If yes, please describe:

2

Does your child require medication to be administered on a daily basis by the staff of the Guelph Outdoor Preschool? Yes_ No_ If yes, please describe and fill out a separate Medication Form

Authorized Release Person(s)

Are there any individuals other than yourself to whom your child may be released? Yes _No_

If yes, please list below (attach separate sheet for more names) 1.) 2.) 3.) 4.)

Are there any individuals to whom your child MUST NOT see or associate with? Yes_No_

If yes, give name(s) and procedures to follow if they arrive at the preschool

Signed

Date:

3

CONFIDENTIAL

DEVELOPMENTAL HISTORY To Be Completed By A Parent Or Guardian

The following questions have been designed to assist the staff in understanding your child. The information is extremely helpful in planning and providing responsive, individual care for him/her. Please note that some of the following questions may not apply to all children.

Family Life Name of child

Nickname

Parent/Guardian 2 Name

Name child uses_

Parent/Guardian 1 Name Marital Status of Parents/Guardians:

Name child uses

Married/Common law_ Widowed_ Divorced_ Separated_ Single_ Are there any special custody arrangements? Yes_ No_ If yes, please explain

Brothers and Sisters: Name

Age

Name

Age

Name Name

Age Age

Are there any other people living in the household? Yes_ No_ If yes, who?

What is the Ethnic Background of the family? What language(s) are spoken within the home?

4

Does your child understand English? Yes_ No_

Daily Living What are your child’s typical eating patterns?

What foods does your child like?

What foods does your child dislike?

Do you have any concerns about your child’s eating habits

What are your child’s regular toileting routines?

How does your child indicate his/her need to use the washroom? Are any special words used for toileting or body parts? Yes_ No_ If yes, please explain

What time does your child go to bed at night?

He/She sleeps for

hours at night

Does your child take a nap during the day? Yes_ No_ Sometimes_ If yes, what time?

How long?

Are there any special comforters your child uses to help go to sleep (soft toy, blanket, sucking thumb)?

5

What routines are used at home to help your child go to sleep?

Health

Does your child have any ongoing medical conditions? Yes_ No_ If yes, please describe

Please see supervisor to fill out Medication Forms if your child requires medication (prescription or overthe-counter) to be administered at the Guelph Outdoor Preschool, Please see supervisor to complete an Individual Anaphylaxis Emergency Plan Form if your child has a life-threatening allergy. Please see supervisor to complete a personalized Medical Plan for your child if applicable

What signs/symptoms does your child typically display upon ill health (fatigue, fever, hives.)?

Social Development What activities does your child enjoy?

How does your child typically react to an argument/disagreement with friends (hits, withdraws, etc.)?

Is your child afraid of any particular person or thing (dogs, storms, loud noises, etc.)?

What comforts your child when afraid or upset?

6

How do you discipline your child at home to discourage inappropriate behaviours?

Do you have any concerns about your child’s development (social/emotional, physical, cognitive, language)?

How do you expect your child to adjust to the Guelph Outdoor Preschool? (Circle) Easily adjust

Shy at first, but quickly become comfortable

Shy at first and slowly become comfortable

Frightened

Unsure

Other/Comments

Is there any other information not covered in this form that would help us better understand your child?

Signed

Date

7

Immunization Data Form (for Child Care Settings) Please complete sections 1, 2, 3 and 4 (Please PRINT clearly) Return this form to your child’s daycare/nursery school 1. Child’s Last Name:

First Name:

Date of Birth: Year/Month/Day

Boy

(

)

Girl

(

)

Child’s Ontario Health Card Number:

__ __ __ __ -__ __ __ -__ __ __

Mother’s Name:

Father’s Name:

Home Address:

Home Address:

City and Postal Code:

City and Postal Code:

Home Phone:

(

)

__ __ __ - __ __ __ __

Home Phone:

(

)

__ __ __ - __ __ __ __

2. Name of Daycare/Nursery School attending: Name of Junior Kindergarten/Kindergarten attending: Physician:

Phone:

3. Immunization History:

Immunization Record Fiche d’immunisation

Please attach a photocopy of all of your child’s records (since birth) to this form

Name Nom ________________________________________ Date of Birth Date de naissance

In order to attend Daycare in Wellington-Dufferin-Guelph, you must provide a complete history of your child’s immunization to Public Health (Medical Officer of Health). Parents who do not wish their child to be immunized for medical, conscience or religious reasons may obtain an exemption form by contacting their local Public Health office. The Day Nurseries Act, requires that children attending licensed daycare in Ontario have up-to-date immunization against six designated diseases: diphtheria, tetanus, polio, measles, mumps and rubella (German measles).

________________________________________ (yyyy/mm/dd) (aaaa/mm/jj) Ontario Health Card Number Numéro de Carte Santé de l’Ontario ________________________________________

of Health Ontario Ministry and Long-Term Care

Ministère de la Santé et des Soins de longue durée

It is the parent/guardian’s responsibility to maintain a record of immunization for their children and inform Wellington-DufferinGuelph Public Health as additional immunization is given. If you are unable to complete this form or cannot locate your child’s record, please contact your previous physician or call Public Health for assistance.

4. Date:______________________

Parent/Guardian’s Signature:_____________________________________

The information on this form is collected under the authority of Health and Promotion Act in accordance with the Municipal Freedom of Information Protection Act and Privacy Act and the Provincial Health Information Protection Act. This information will be used for the delivery of public health programs and services, the administration of the organization, the maintenance of health care databases, registries and related research and compliance with legal and regulatory requirements. Any questions about this collection should be addressed to the Director of Administration.

CHDPVP(F)118-06/2008

CONFIDENTIAL

PERMISSION TO TAKE PART IN FIELD TRIPS I hereby give permission for my child to take part in walks, field trips and other excursions on the Ignatius Jesuit Centre property, provided he/she is supervised at all times by a qualified staff member. I understand that I will be notified in advance of any major activity that requires my child to leave the Ignatius Jesuit Centre property and when the field trip requires transportation. Parent/Guardian Signature:

Date:

Publicity Consent

I hereby give permission for my child to participate in any publicity arranged for the Guelph Outdoor Preschool through various media such as newspapers, photographs, television, slide presentations and videos. I understand that, whenever possible, I will be notified prior to the event and, when this is not possible, I will be notified after the event. Parent/Guardian Signature:

Date:

9

PARENT CONTRACT I have read the Guelph Outdoor Preschool’s Parent Handbook and understand and agree to all its’ policies, terms and conditions. Parent/Guardian Name: Signature:

Date:

Witness Signature:

10