2017/18 - Infant, Toddler & Preschool Enrollment Health Forms

Infant, Toddler, Preschool Health Forms

Completion of these questions does not confirm your child's enrollment. You must follow up with Director for program availability and pay the registration fee (if required).
Student Name *

First Name Last Name
Nickname - What does the child preferred to be called?
Date of Birth *

- Month - Day Year
Age
Select One

Male Female
YMCA Location *
School District of Residence
First Day of School (Please enter your desired school/enrollment starting date) *

/ Month / Day Year
Child / Family Information Survey
Please list immediate child family members and relationship.
Who lives at home with your child? Are there any specialm family arrangements, such as shared parenting, living in two homes, or custody specifications, etc.
Are there any changes or transitions that your child has recently experienced or is experiencing? (divorce, new home, death of family member, friend or pet)
What is the primary language spoken in your child's home?
Are there any cultural or religious practices of your family we should be aware of? (Dietary restrictions, clothing, head coverings, etc.)
Does your child have any favorite foods, or dislike any food?
Are there things that frighten your child? If so, how does he/she react what do you do to comfort him/her?
What causes your child to feel angry or frustrated?
What are effective strategies that you use to redirect your child's behavior?
Please provide any additional information that you think is important or may affect the child's ability to fully participate in our program.
What goals do you have for your child while they're in our program? What do you hope your child learns and experience?
Parent / Gaurdian Involvement Survey
Are you interested in joining a Parent Advisory Committee?

Yes No
If YES, What days / times would be convenient for you?
Or could you see yourself being involved by:
Would anyone else in your family like to volunteer? Please name and provide contact information.

Parent / Guardian Statement of Understanding and Policies
Policies and Procedures/Handbooks
Acknowledgement of Policies and Procedures I have reviewed and received a copy of the center's policies and procedures/handbook. *

Yes No
Photography/Videography Release: Choose the appropriate response in regards to YMCA staff photographing or videotaping my child for YMCA promotional purposes (ads, brochures, newspapers, recruitment videos,) or for on-site activity purposes *

I give the YMCA staff permission to take my child’s picture for promotional purposes or onsite activities. I do not give the YMCA staff permission to take my child’s picture for promotional purposes or onsite activities.
Signature
The YMCA of Central Ohio’s Employee Code of Conduct related to the interactions between YMCA Staff and program participants, members and volunteers. The YMCA of Central Ohio is committed to keeping its program participants, members, volunteers, staff and the community safe.

We feel that it is important to share with you the expectations that we have of our staff regarding their interactions with program participants, members, volunteers, fellow staff, and the community. Please review and retain a copy of this document describing our expectations.

Parent/Guardian 1
Parent/Guardian 1 *

First Name Last Name
Relationship to Child *
E-mail *
Cell Phone *
Home Phone *

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent's Work/School Name *
Or enter N/A if not applicable
Parent's Work/School Phone *

Parent's Work/School Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Please indicate if this name should be released if a parent/guardian, of a child attending the center/home, requests contact information for other parents/guardians. *

Yes No
If you answered yes, please indicate which numbers above to include on the list

Work #
Cell #
Home #
Email
Where would you like to be reached while your child is in the program?

Cell Phone Work Phone Home Phone
Contact preference
Where can you be reached while your child is in this program?
Should a Second Parent be listed? *

Emergency Contacts/Authorized Pickup

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.
Emergency Contact #1 - Required
Full Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Phone Number *
Secondary Phone Number *
Relationship to Child *

Emergency Contact #2
Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Phone Number
Secondary Phone Number
Relationship to Child

Emergency Contact #3
Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Phone Number
Secondary Phone Number
Relationship to Child

Emergency Contact #4
Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Phone Number
Secondary Phone Number
Relationship to Child

Plan for Health Conditions
If care is provided for a child who has an ongoing health condition that requires child specific care or may require a medical procedure, the parent/guardian shall complete this form.

A separate plan must be written for each condition that requires different actions to be taken.

If the child has more than 1 medical condition that requires different actions to be taken, answer the fields below for the first condition. Additional conditions must be addressed using this separate form.
Special Health Conditions *

0/100
Symptoms to watch for and emergency action to be taken if the following symptoms occur *

0/250
Activities/foods/environmental conditions to avoid, if applicable *

0/150
Medical procedures to be followed and expected benefit of treatment, if applicable *

0/250
Are any medication required? *

Yes No
If yes, what medications? (If yes, complete JFS 01217 "Request for Administration of Medication") *

0/150
In an emergency does this child require additional assistance (more than other children of the same age or in the same group) to evacuate? *

Yes No
In the event that the child care program must be evacuated, are there medications or supplies that must be taken with this child? *

Yes No
Upload additional completed care plans.

Additional Medication (Administration of Medication JFS 01217)
Weight *
Check all that apply

Prescription medication
Nonprescription medication
Food supplement
Topical product or lotion
Refrigeration required
Modified diet
Name of medication *
Exact dosage *
To be administered at the following times *
For the following period of time *
I understand that my child must receive one dose of medication before arriving at the program (unless the medication is used for emergencies).

Check Box
If your child's medication meets any of these criteria:
1. A physician's instruction is needed for a nonprescription medication (e.g. child is underage or underweight per the label instructions); or
2. It is a sample medication without a prescription label; or
- The nonprescription medication is to be given longer than three consecutive days within a fourteen day period or is a topical product or lotion that is being used for a skin ailment and is to be given no longer than fourteen consecutive days; or
1. The child is on a modified diet (an entire food group is eliminated); or
2. The medication contains codeine or aspirin.
Please complete this form and Box 2 must be completed by a licensed physician, licensed dentist, or an advance practice nurse.
Upload a Scanned File of the Completed Form

List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation. *

0/200
List any additional information about your child that would be useful for staff to know, such as fears, eating or sleeping habits, or special routines. This information should not be medical or health related, as that information should be included in the previous questions. *

0/200
The YMCA of Central Ohio has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported. *
Type first and last name above to consent
This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the administrator/designee prior to the child receiving care. After the child is attending the program the administrator shall have the parent/guardian review and initial the form when any changes/updates are made and at least annually. The parent/ guardian and the administrator or designee shall initial and date the form in the section below to indicate when the form was last reviewed. *
Type first and last name above to consent
Sign Document *
Date Signed *

- Month - Day Year
Child Care Director and Contact Info
directoremail

Infant, Toddler, Preschool Health Forms

Child / Family Information Survey

Parent / Gaurdian Involvement Survey

Parent / Guardian Statement of Understanding and Policies

Emergency Contacts/Authorized Pickup

Medical / Health Information

Plan for Health Conditions

Additional Medication (Administration of Medication JFS 01217)

United Way Required Documentation