Fillable CHILDS APPLICATION FOR ENROLLMENT (Camden County Schools)

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CHILDS APPLICATION FOR ENROLLMENT (Camden County Schools)

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Date Application Completed____________________ Date of Enrollment________________
CHILD’S APPLICATION FOR ENROLLMENT
To be completed, signed, and placed on file in the facility on the first day and updated as changes occur and at least annually
Revised 3/2017
Camden County Schools
CHILD INFORMATION: Date of Birth: ______________________________________
Full Name:
____________________________________________________________________________________________________________________________
Last First Middle Nickname
Child's Physical Address: _____________________________________________________________________________________________________________
FAMILY INFORMATION: Child lives with: _________________________________________________________________________
Father/Guardian’s Name ____________________________________________________________ Home Phone______________________________________
Address (if different from child’s) ______________________________________________________________ Zip Code__________________________________
Work Phone __________________________________________________________________ Cell Phone____________________________________________
Mother/Guardian’s Name ___________________________________________________________ Home Phone______________________________________
Address (if different from child’s) ______________________________________________________________ Zip Code__________________________________
Work Phone __________________________________________________________________ Cell Phone_________________________
CONTACTS: Please list the names of individuals to whom the center may release the child, as authorized by the person who signs the application. The operator,
administrator, and staff shall release a child only to an individual(s) listed on the application.
__________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
HEALTH CARE NEEDS:
For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be
attached to the application. The medical action plan must be completed by the child’s parent or health care professional.
Is there a medical action plan attached? Yes__ No__
List any allergies and the symptoms and type of response required for allergic reactions. ___________________________________________________________
__________________________________________________________________________________________________________________________________
List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns. ______________________________________
___________________________________________________________________________________________________________________________________
List any particular fears or unique behavior characteristics the child has__________________________________________________________________________
List any chronic illness the individual has and any medication taken for that illness__________________________________________________________________
Share any other information that has a direct bearing on assuring safe medical treatment for your child__________________________________________________
___________________________________________________________________________________________________________________________________
EMERGENCY MEDICAL CARE INFORMATION:
Emergency medical care information must be on file for each individual child. This information must include the name, address, and telephone number of the
parent or
other person to be contacted in case of an emergency.
__________________________________________________________________________________________________________________________________
Name Address Phone Number
___________________________________________________________________________________________________________________________________
Name Address Phone Number
Name of health care professional _____________________________________________________________ Office Phone_______________________________
Hospital preference ________________________________________________________________________ Phone_____________________________________
I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency.
Signature of Parent/Guardian_______________________________________________________________Date________________________________________
I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of emergency. In an emergency, other children in the facility will
be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the child’s parent, guardian,
or full-time custodian.
Signature of Administrator__________________________________________________________________Date________________________________________
Revised 8.09
Camden County Schools After School Daycare and Summer Programs
Discipline and Behavior Management Policy
Date Adopted ________________
Praise and positive reinforcement are effective methods of the behavior management of
children. When children receive positive, non-violent, and understanding interactions from
adults and others, they develop good self-concepts, problem solving abilities, and self-discipline.
Based on this belief of how children learn and develop values, this facility will practice the
following discipline and behavior management policy:
We:
1. DO praise, reward, and encourage the
children.
2. DO reason with and set limits for the
children.
3. DO model appropriate behavior for the
children.
4. DO modify the classroom environment
to attempt to prevent problems before
they occur.
5. DO listen to the children.
6. DO provide alternatives for
inappropriate behavior to the children.
7. DO provide the children with natural
and logical consequences of their
behaviors.
8. DO treat the children as people and
respect their needs, desires, and
feelings.
9. DO ignore minor misbehaviors.
10.DO explain things to children on their
levels.
11.DO use short supervised periods of
time-out sparingly.
12.DO stay consistent in our behavior
management program.
13.DO use effective guidance and
behavior management techniques that
focus on a child’s development.
We:
1. DO NOT spank, shake, bite, pinch,
push, pull, slap, or otherwise
physically punish the children.
2. DO NOT make fun of, yell at,
threaten, make sarcastic remarks
about, use profanity, or otherwise
verbally abuse the children.
3. DO NOT shame or punish the children
when bathroom accidents occur.
4. DO NOT deny food or rest as
punishment.
5. DO NOT relate discipline to eating,
resting, or sleeping.
6. DO NOT leave the children alone,
unattended, or without supervision.
7. DO NOT place the children in locked
rooms, closets, or boxes as
punishment.
8. DO NOT allow discipline of children
by children.
9. DO NOT criticize, make fun of, or
otherwise belittle children’s parents,
families, or ethnic groups.
I, the undersigned parent or guardian of _______________________________
(child's full name), do hereby state that I have read and received a copy of the facility's Discipline and
Behavior Management Policy and that the facility's director/operator (or other designated staff member)
has discussed the facility's Discipline and Behavior Management Policy with me.
Date of Child's Enrollment: __________________________________________
Signature of Parent or Guardian _______________________________________ Date ____________________
Distribution: one copy to parent(s) signed copy in child's facility record
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Camden County Schools
Revised 8.09
TRAVEL AND ACTIVITY AUTHORIZATION
Blanket permission for this activity
Special 1-time permission only
Camden County Schools
Blanket permission for all given activities
I, _________________________________ ________________________ parent/guardian of
name of parent/guardian
__________________________________________________________________________give my permission to
name of child
_____________________________________________________________________for my child to participate in the
following activities
Trips in the van/automobile (facility or parent-owned)
___________________________________________________________________________
Explain planned activity — where and when
Field trips away from the facility
____________________________________________________________________________
Explain planned activity — where and when
I understand that the facility will use the appropriate child restraint devises and abide by all the
safety rules in Rule .1000 when my child is transported in a vehicle. The facility will also notify me each time that my child is to
participate in an activity that would involve transportation.
_________________________________________
Parent/Guardian Signature
_______________________________________________________
Date Signed
This authorization is valid from ______/______/______ to ______/______/______
In addition, if the facility has planned activities outside the fenced area of the facility,
_______ I will allow my child to play outside the fenced area; or
_______ I will not allow my child to play outside the fenced area.
_________________________________________
Parent/Guardian Signature
_______________________________________________________
Date Signed
This authorization is valid from ______/______/______ to ______/______/______
File in child's folder
10 NCAC 3U .0604(1)
G. S. 110-91(6)
REV 8/92
name of
facility
The following requirements apply to both centers and
homes.
Transportation
Child care centers or family child care homes providing
transportation for children must meet all motor vehicle laws,
including inspection, insurance, license, and restraint
requirements. Children may never be left alone in a vehicle
and child-staff ratio must be maintained.
Program Records
Centers and homes must keep accurate records such as
children's attendance, immunizations, and emergency
phone numbers. A record of monthly fire drills and quarterly
shelter-in-place or lockdown drills practiced must also be
maintained. A safe sleep policy must be developed and
shared with parents if children younger than 12 months are
in care.
Discipline and Behavior Management
Each program must have a written policy on discipline,
must discuss it with parents, and must give parents a copy
when the child is enrolled. Changes in the discipline policy
must be shared with parents in writing before going into
effect. Corporal punishment (spanking, slapping, or other
physical discipline) is prohibited in all centers and family
child care homes. Religious-sponsored programs which
notify the Division of Child Development and Early
Education that corporal punishment is part of their religious
training are exempt from that part of the law.
Parental Rights
Parents have the right to enter a family child care
home or center at any time while their child is
present.
Parents have the right to see the license displayed
in a prominent place.
Parents have the right to know how their child will
be disciplined.
The laws and rules are developed to establish minimum
requirements. Most parents would like more than minimum
care. Child care resource and referral agencies can provide
help in choosing quality care. Check the telephone directory
or talk with a child care provider to see if there is a child
care resource and referral agency in your community. For
more information visit the Resources in Child Care website
at: www.ncchildcare.nc.gov . For more information on the
law and rules, contact the Division of Child Development
and Early Education at 919-527-6335 or 1-800-859-0829
(In State Only), or visit our homepage at:
ncchildcare.nc.gov
Reviewing Files
A public file is maintained in the Division’s main office in
Raleigh for every center or family child care home.
These files can be
viewed during business hours (8 a.m. -5 p.m.);
requested via the Division’s web site at
www.ncchildcare.nc.gov; or
requested by contacting the Division by telephone
at 919-527-6335 or 1-800-859-0829 -800-859-
0829.
How to Report a Problem
North Carolina law requires staff from the Division of
Child Development and Early Education to investigate
a licensed family child care home or child care center
when there has been a complaint. Child care
providers who violate the law or rules may be issued
an administrative action, fined and may have their
licenses suspended or revoked. If you believe that a
child care provider fails to meet the requirements
described in this pamphlet, or if you have questions,
please call the Division of Child Development and
Early Education at 919-527-6500 or 1-800-859-0829.
Child Abuse, Neglect, or Maltreatment
Every citizen has a responsibility to report suspected
child abuse, neglect or maltreatment. This occurs
when a parent or caregiver injures or allows another
to injure a child physically or emotionally. It may also
occur when a parent or caregiver puts a child at risk
of serious injury or allows another to put a child at risk
of serious injury. It also occurs when a child does not
receive proper care, supervision, discipline, or when a
child is abandoned. North Carolina law requires any
person who suspects child maltreatment at a
child care facility to report the situation to the
Intake Unit at Division of Child Development and
Early Education at 919-527-6335 or 1-800-859-
0829. Reports can be made anonymously. A person
cannot be held liable for a report made in good faith.
The operator of the program must notify parents of
children currently enrolled in writing of the
substantiation of any maltreatment complaint or the
issuance of any administrative action against the child
care facility. North Carolina law requires any
person who suspects child abuse or neglect in a
family to report the case to the county department
of social services.
Summary of the
North Carolina
Child Care
Law and Rules
Division of Child Development
and Early Education
North Carolina Department of
Health and Human Services
820 South Boylan Avenue
Raleigh, NC 27699
Revised March 2016
The North Carolina Department of Health and
Human Services does not discriminate on the basis
of race, color, national origin, sex, religion, age or
disability in
employment or provision of services.
What Is Child Care?
The law defines child care as:
three or more children under 13 years of age
receiving care from a non-relative
on a regular basis - at least once a week
for more than four hours per day but less than
24 hours.
The North Carolina Department of Health and Human
Services is responsible for regulating child care. This is
done through the Division of Child Development and
Early Education. The purpose of regulation is to protect
the well-being of children while they are away from their
parents. The law defining child care is in the North
Carolina General Statutes, Article 7, Chapter 110.
The North Carolina Child Care Commission is
responsible for adopting rules to carry out the law.
Some counties and cities in North Carolina also have
local zoning requirements for child care programs.
Star Rated Licenses
Centers and homes that are meeting the minimum
licensing requirements will receive a one star license.
Programs that choose to voluntarily meet higher
standards can apply for a two through five star license.
The number of stars a program earns is based upon
the education levels their staff meet and the program
standards met by the program.
Family Child Care Homes
A family child care home is licensed to care for five or
fewer preschool age children, including their own
preschool children, and can include three additional
school-age children. The provider's own school-age
children are not counted. Family child care homes will
be visited at least annually to make sure they are
following the law and to receive technical assistance
from child care consultants. Licenses are issued to
family child care home providers who meet the following
requirements:
Home providers must be 21 years old with at least
a high school education or its equivalent, and
mentally and emotionally capable of caring for
children.
He or she must undergo a criminal records
background check initially, and every three years
thereafter.
All household members over age 15 must also
undergo a criminal records background check
initially, and every three years thereafter.
All family child care home providers must have
current certification in CPR and first aid,
complete an ITS-SIDS training (if caring for infants
0 -12 months) every three years and the
Emergency Preparedness and Response in Child
Care training and plan. They also must complete a
minimum number of training hours annually.
All family child care homes must meet basic health and
safety standards. Providers must maintain verification of
children’s immunization and health status. They must
provide developmentally appropriate toys and activities,
as well as nutritious meals and snacks for the children in
care. All children must participate in outdoor play at
least one hour per daily, if weather conditions permit.
Child Care Centers
Licensing as a center is required when six or more
preschool children are cared for in a residence or when
three or more children are in care in a building other
than a residence. Religious-sponsored programs are
exempt from some of the regulations described below if
they choose to meet the standards of the Notice of
Compliance rather than the Star Rated License.
Programs that operate for less than four consecutive
months, such as summer camps, are exempt from
licensing. Child care centers may voluntarily meet
higher standards and receive a license with a higher
rating. Centers will be visited at least annually to make
sure they are following the law and to receive technical
assistance from child care consultants.
Licensed centers must meet requirements in the
following areas.
Staff
The administrator of a child care center must be at least
21, and have at least a North Carolina Early Childhood
Administration Credential or its equivalent. Lead
teachers in a child care center must be at least 18 and
have at least a North Carolina Early Childhood
Credential or its equivalent. If administrators and lead
teachers do not meet this requirement, they must begin
credential coursework within six months of being hired.
Staff younger than 18 years of age must work under the
direct supervision of staff 21 years of age or older. All
staff must complete a minimum number of training hours
including ITS-SIDS training for any caregiver that works
with infants 12 months of age or younger. At least one
person on the premises must have CPR and First Aid
training. All staff must also undergo a criminal records
background check initially, and every three years
thereafter. One staff must complete the Emergency
Preparedness and Response in Child Care training and
plan.
Staff/Child Ratios
Ratios are the number of staff required to supervise a
certain number of children. Group size is the maximum
number of children in one group. Ratios and group sizes
for licensure are shown below and must be posted in
each classroom.
Age Teacher: Child Ratio Max Group Size
0-12 mths 1:5 10
12-24mths 1:6 12
2 years old 1:10 20
3 years old 1:15 25
4 years old 1:20 25
1:25 25
Small centers in a residence that are licensed for six to twelve
children may keep up to three additional school-age children,
depending on the ages of the other children in care. When the
group has children of different ages, staff-child ratios and group
size must be met for the youngest child in the group.
Space and Equipment
Centers must have at least 25 square feet per child
indoors and 75 square feet per child outdoors. Outdoor
play space must be fenced. Indoor equipment must be
clean, safe, well maintained, and developmentally
appropriate. Outdoor equipment and indoor furnishings
must be child size, sturdy, and free of hazards that
could injure children.
Curriculum
Four and five star programs must use an approved
curriculum in their four-year-old classrooms. Other
programs may choose to use an approved curriculum to
get a quality point for the star-rated license. Activity
plans must be available to parents and must show a
balance of active and quiet, and indoor and outdoor
activities. Rooms must be arranged to encourage
children to explore, use materials on their own and have
choices.
Health and Safety
Children must be immunized on schedule. Each
licensed center must ensure the health and safety of
children by sanitizing areas and equipment used by
children. Meals and snacks must be nutritious, and
children must have portions large enough to satisfy their
h
unger. Food must be offered at least once every four
hours. Local health, building, and fire inspectors visit
licensed centers to make sure standards are met. All
children must be allowed to play outdoors each day
(weather permitting) for at least an hour a day for
preschool children and at least thirty minutes a day for
children under two. They must have space and time
provided for rest.
CAMDEN COUNTY SCHOOLS
AFTER SCHOOL/SUMMER DAYCARE PROGRAM
ACKNOWLEDGEMENT FORM
My signature below indicates that I have received and completed the
following forms below:
1. Child’s Application for Child Care
2. Discipline and Behavior Management Policy
3. Travel and Activity Authorization
4. North Carolina Child Care Laws and Rules
5. Acknowledgement Form
I, as the parent/guardian, also acknowledge that I received information
on where to access and review the Parent/Student Handbook. I also
acknowledge I have read this handbook and concur with the conditions
as stated.
Child’s Full Name:___________________________________________
__________________________ ______________
Parent/Guardian’s Signature Date
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CHILDS APPLICATION FOR ENROLLMENT (Camden County Schools)

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Completed 10 January 2021

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