Control Record

    Note: all fields showing * are required

    All Childs info is correct and has no new changes

    * Parent's Email

    * Parent's Cell Phone

    * Today's Date

    * Prefer to be contacted by:

    * Your Name

    * Parent Signature

    LITTLE PEOPLES CHILDCARE LLC

    542 NAULTON ROAD

    CURWENSVILLE, PA 16833

    814-236-1942

    THIS CONTRACT IS FOR A PERIOD OF SIX MONTHS. IN WHICH YOUR CHILD WILL BE REQUIRED TO BE IN CARE FOR AT LEAST SIX MONTHS. THIS CONTRACT WILL CONTINUESLY RENEW ITSELF AT THE END OF THE SIX MONTHS UNLESS A 30 DAY WRITTEN NOTICE IS GIVEN. ALL CONTRACTS ARE LEGAL AND WILL BE UPHELD IN A COURT OF LAW.

    EVERY CHILD IN DAYCARE WILL BE PROVIDED WITH MEALS, SNACKS, AND DAILY ACTIVITIES AND SOME EXTRA ACTIVITIES AND TRIPS WILL BE PLANNED IN WHICH EACH CHILD WILL BE REQUIRED TO HAVE A PERMISSION SLIP AND THE CHILD WILL NEED TO BE PROVIDED WITH HIS/HER OWN MONEY FOR THAT DAY.

    RATES

    A FULL-TIME RATE IS CONSIDERED ANYTIME BETWEEN 6:00 AM AND 6:00 PM AND THE RATE IS $175.00 PER WEEK FOR UP TO 9 HOURS EACH DAY. ANYTHING AFTER 9 HOURS IS AN ADDITIONAL $5.00 PER HOUR PER CHILD.

    A PART-TIME RATE IS CONSIDERED ANYTIME BETWEEN 6:00 AM AND 6:00 PM AND THE RATE IS $175.00 PER WEEK FOR UP TO 4 HOURS EACH DAY. HOURS BEFORE 6:00 AM AND AFTER 6:00 PM IS AN ADDITIONAL $5.00 PER HOUR.

    ALL CHILDREN WILL BE CHARGED BY THE NUMBER OF SCHEDULED DAYS. THESE FEES WILL BE ADMISSABLE WHETHER YOU CHILD HAS ATTENDED OR IS ABSENT FOR ANY REASON. THIS ALSO INCLUSES MY DAYS OFF. THIS IS IN ORDER TO RESERVE YOUR CHILDS SPOT AT LITTLE PEOPLES CHILDCARE LLC.

    THERE WILL BE A LATE FEE OF $25.00 PER DAYFOR EVERY DAY THAT YOUR PAYMENT IS NOT PAID BY 5:00 THAT DAY, IT WILL BE CONSIDERED TO BE LATEA DN YOU WILL BE ASSESSSED THIS FEE.

    ALL PARENTS AND GUARDIANS ARE REQUIRED TO GIVE A SCHEDULED DROP OFF AND PICK UP TIME. THERE WILL BE A $5.00 CHARGE FOR EVERY 15 MINUTES THE CHILD IS NOT PICKED UP.

    TERMINATION POLICY

    THE PROVIDER DOES HAVE THE RIGHT TO TERMINATE ANY CLIENT FOR NON-COMPLIANCE OF PROEDURES AND POLICES, THEY WILL RECIEVIE ONE ORAL WARNING AND ONE WRITTEN WARNING WHICH WILL BE DOCUMENTED AND PUT INTO THEIR FILE AND IF FOR ANY REASON THE CLIENT STILL WILL NOT FOLLOW POLICIES, THEIR CHILDCARE WILL BE TERMINATED.

    ANY FEES THAT HAVE NOT BEEN PAID FOR FIVE OR MORE DAYS MAY HAVE FUTHER LEGAL ACTION TAKEN IN ORDER TO RECEIVE ALL PAYMENTS DUE TO THE CHILDCARE FACILITY. AT THIS TIME THE CLIENT WILL BE RESPONSIBLE FOR ANY AND ALL LEGAL FEES.

    POLICIES AND PRECEDURES

    LITTLE PEOPLES CHILDCARE IS IN MY HOME IN WHICH I PROVIDE A CLEAN, SAFE, HEALTHY AND LOVING PLACE FOR THE CHILDREN TO BE. I WILL EXPECT IN RETURN THAT YOU AND YOUR CHILDREN RESPECT MY BELONGINGS. PLEASE TAKE YOUR SHOES OFF AT THE DOOR. THISIS A BIG PROBLEM WITH ME. DO NOT WALK ON ANY CARPETED AREAS WITH YOUR SHOES ON AND DO NOT LET YOUR CHILDREN. THE CHILDREN PLAY AND LAY ON FLOORS IT MUST BE KEPT CLEAN AT ALL TIMES.

    DISCRIMINATION ACT

    MY DAYCARE IS OPEN TO ALL CHILDREN REGARDLESS OF RACE, COLOR, SEX, HANDICAP, RELIGION, OR NATIONAL ORIGIN. GOOD PROGRAMS GET BETTER WHEN THE INCLUDE CHILDREN WITH A WIDE RANGE OF INTERESTS AND EXPERIENCE. LITTLE PEOPLES CHLDCSARE SUPPORTS THE RIGHTS OF CHILREN WITH DISABILITIES TO GROW AND LEAN ALONGSIDE THEIR TYPICALLY DEVELOPING PEERS, INTEGRATING CHILDREN WITH AND WITHHOUT SPECIAL NEEDS INCREASES THE OPPORTUNITIES FOR ALL THE CHILDREN TO LEARN ABOUT AND ACCEPT INDIVIDUAL DIFFERENCES.

    DISCIPLINE AND BEHAVIOR OF YOUR CHILDREN

    MOST OF MY DISCIPLINE CONSISTS OF A TIME OUT PERIOD, BASED ON THE CHILDS AGE IT HOW LONG THEY WILL BE ON THE TIMEOUT CHAIR. HOWEVER, IF FOR ANY REASON WE NEED TO SPEAK ON THE ISSUE, WE WILL DO SO AT THE PROPER TIME, NOT WHEN I AM BUSY GETTING EVERYONE READY TO LEAVE OR IN FRONT OF ANY OTHER CHILDREN OR PARENTS, I ALSO EXPECT YOUR CHIDLREN TO BEHAVE AS THEY WOULD WHETHER OR NOT YOU ARE HERE.

    HOLIDAYS AND VACATION DAYS

    ALL HOLIDAYS AND VACATION DAYS PER YEAR ARE PAID TIME OFF FOR ME AND MY FAMILY, ALL DAY'S OFF WILL BE AT LEAST A 48 HOURS NOTICE. SOME EMERGENCIES AND ILLNESSES CANNOT BE PREDICTED AND THEREFORE MAY NOT HAVE ANY NOTICE.

    HEALTH ASSESSMENTS

    HEALTH ASSESSMENTS MUST BE FILLED OUT ACCORDING TO THE DEPARTMENT OF PUBLIC WELFARE GUIDELINES. YOU HAVE 30 DAYS FROM THE ENROLLMENT DATE TO RETURN THESE FORMS. IF THE FORMS ARE NOT TURNED IN YOU WILL NOT HAVE CHILDCARE AND WILL STILL BE RESPONSIBLE TO PAY YOUR FEES.

    AGGREEMENT FORMS, EMERGENCY CONTACT FORMS AND ALL OTHER PAPERWORK

    ALL FORMS MUST BE TURNED IN ON THE 1ST DAY OF CARE. THESE FORMS MUST ALSO BE UPDATED AT LEAST EVERY SIX MONTHS. YOU MAY JUST SIGN AND DATE YOUR CONTROL SHEET IF THERE ARE NOT ANY CHANGES. IF FOR ANY REASON YOUR INFORMATION HAS CHANGED YOU WILL NEED TO UPDATE ALL OF YOUR FORMS.

    DIAPERING

    THE PARENT OR GUARDIAN MUST SUPPLY ALL DIAPERS AND WIPES, IF FOR ANY REASON I HAVE TO PURCHASE DIAMPERS OR WIPES; THE COST WILL BE ADDED TO YOUR WEEKLY FEE. EACH CHILD MUST HAVE A PERMISSION SLIP FOR DIAPER OINMENT OR BABY POWDER AND HAS TO BE LABELED WITH THE CHILDS NAME ON THE BOTTLE.

    BOTTLES AND DRINKING CUPS

    ALL CHILDREN MUST HAVE THEIR BOTTLES AND DRINKING CUPS LABELED WITH THE CHILDS NAME HOWEVER I DO SUPPLY BOTTLES AND cups BUT IF YOU CHOOSE TO BRING THEM, THEY MUST BE LABELED.

    SMOKING

    SMOKING IS NOT PERMITTED AT THE FACILITY AT ANY TIME. PLEASE DO NOT PUT YOUR CIGARETTE BUTTS IN THE DRIVEWAY OR ANYWHERE AT MY HOME. CIGARETTE BUTTS ARE VERY TOXIC AND CHILDREN CAN ALSO CHOKE ON THEM. THIS WILL NOT BE TOLERATED AND IF IT BECOMES A PROBLEM THEN YOUR CARE MAY BE TERMINATED.

    FIREARMS

    AT THIS TIME, WE DO NOT HAVE ANY FIREARMS IN ANY LOCATION AT THE FACILITY.

    SICK POLICY

    THERE ARE A FEW REASONS WHY YOU SHOULD NOT BRING YOUR CHILD TO DAYCARE WHEN THEY ARE SICK. I HAVE MANY OTHER CHILDREN TO CARE FOR AND I AM RESPONSIBLE TO ENSURE THAT THEY ARE KEPT HEALTHY. SYMTOMS REQUIRING THE CHILD NOT TO COME TO DAYCARE ARE AS FOLLOWS; FEVER, SORE THROAT (SEVERE COUGHING), RASH, VOMITING (l CAN NOT CLEAN THIS UP, SO PLEASE, PLEASE DO NOT BRING THEM IF THEY HAVE BEEN VOMITING THE NIGHT BEFORE) DIARRHEA, AND EARACHE. FEVER IS DEFINED AS HAVING A TEMP OF 101 DEGREES OR HIGHER

    Inclusion

    Little Peoples Childcare LLC believes that children of all ability levels are entitled to the same opportunities for participation, acceptance and belonging in child care. We will make every reasonable accommodation to encourage full and active participation of all children in our program based on his/her individual capabilities and needs. I welcome all children and am committed to providing developmentally appropriate early learning and development experiences that support the full access and participation of each and every child. I believe that each child is unique and work in partnership with families and other professionals involved with the child to provide the support every child needs to reach their full potential.

    Children of all abilities are accepted in to my program and families interest in having their child attend the program will be given an equal opportunity for admission. A waiting list may be maintained and children will be accepted from the list on a first come first serve basis.

    I use developmentally appropriate practices and consider the unique needs of all children when planning. I will make every attempt to make any adaptations or modifications necessary to meet the needs of the children when finally feasible. Schedules, routines and activities are flexible and early childhood educators will work with therapists, special educators and other professionals to integrate individual accommodations, modifications and strategies into classroom routines and activities. Any adaptations will be reviewed with families and other professionals supporting the child.

    Special Care Plans

    Your child's health and safety are a top priority for me. One of the ways I assure I am prepared to meet your child's needs in any situation to the best of my ability is by utilizing special care plans. If your child needs special accommodations or has a long-term health care need such as asthma, allergies, a need for emergency medication, long term medication administration or other medical needs please obtain a special care plan from me. I request that you take the form to your primary care physician and have the form completed and returned to me. Once it is in your child's confidential file at my facility, I am asking that you keep it up to date and current at all times.

    Children in care:

    * Child 1.

    Child 2.

    Child 3.

    Child 4.

    Child 5.

    THIS VERIFIES THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS OF THIS CONTRACT AND THE POLICIES AND PROCEDURES OF THIS FACILITY.

    * Parent Guardian Signature

    * Today's Date

    Agreement

    * Name of child

    * Pay per:

    * Choose day of week for payment:

    Services to be provided as part of the day care fee

    Daily Meals, Snacks, Preschool and Daily Activities

    *Child Arrival Time (Starting at 5:30 am)

    Late Fee: $5.00

    *Childs Departure Time (Ending at 9pm)

    Per MIN-HR: 15 minutes

    *PERSON(S) DESIGNATED BY PARENT TO WHOM CHILD MAY BE RELEASED

    Extra services to be provided at an additional fee if applicable

    I, the Parent/Guardian received complete written program information at the time of enrollment ( Section 3270.121, 3280.121, 3290.121)

    I, the Parent/Guardian agree to update the emergency contact/parental consent form information, whenever changes occur or every 6 months as a minimum. (Section 3270.124, 3280.124, 3290.124)

    *Signature-Parent or Guardian

    * Today's Date

    * Childs Name

    * Childs Birthdate

    * ChildsAddress

    * Mothers Name/Legal Guardian

    * Mother/Guardian's Number

    * Mothers/Guardians Address

    * Mother's Business Name

    * Mother's Business Number

    * Mother's Business Address

    * Father's Name/Legal Guardian

    * Father/Guardian's Number

    * Father/Guardians Address

    * Father Business Name

    * Father Business Number

    * Father Business Address

    * Emergency Contact Person 1

    Emergency Contact Person 2

    Emergency Contact Person 3

    * Emerg Contact 1 # while child is in care

    Emerg Contact 2 # while child is in care

    Emerg Contact 3 # while child is in care

    * Person 1 to whom child may be released

    Person 2 to whom child may be released

    Person 3 to whom child may be released

    * Person 1 address

    Person 2 address

    Person 3 address

    * Person 1 Number while child is in care

    Person 2 Number while child is in care

    Person 3 Number while child is in care

    * Name of child's Physician/Medical Care Provider

    * Medical Care Provider's Number

    * Medical Care Provider's Address

    Special Disabilities (If any)

    Medical or Dietary Information necessary in an emergency situation

    Allergies (Including Medication Reaction)

    Medication, Special Conditions

    * Additional information on special needs of child

    * Health Insurance Coverage for child or Medical Assistance benefits

    * Policy Number

    Parent Signature is required for each item below to indicate parental consent, if not use N/A for decline

    * Obtaining Emergency Medical Care (DO NOT USE TOUCHSCREEN)

    * Walks and Trips (DO NOT USE TOUCHSCREEN)

    * Transportation by the Facility (DO NOT USE TOUCHSCREEN)

    * Admin. of minor first-aid procedures (DO NOT USE TOUCHSCREEN)

    * Swimming (DO NOT USE TOUCHSCREEN)

    * Wading (DO NOT USE TOUCHSCREEN)

    * Signature of Parent or Guardian (DO NOT USE TOUCHSCREEN)

    * Date

    * Signature of Parent or Guardian (DO NOT USE TOUCHSCREEN)

    * Date

    Child's/Family Personal History

    Child's Name

    Height

    Weight

    Birth Date

    With whom does your child live?

    Father/Guardian Name

    Mother/Guardian Name

    Brother(s) Name(s)

    Sister(s) Name(s)

    Other Members of the household (list):

    Has your child been cared for by anyone else?

    Has your child been cared for by anyone other than parents?

    If your child has attended another child care, please name and list for how long.

    Please note if your child has any health or other issues requiring special attention that you feel we should be aware of and note any special measures you would like us to take:

    My child has his/her own room?

    Room Comments?

    My child watches TV

    If yes how often?

    If yes what shows?

    Does your child have playmates?

    Is your child toilet trained?

    What words does your child use when wanting to use bathroom?

    Does your child need help dressing?

    Does your child need help undressing?

    Does your child have any allergies?

    If yes, please list allergies:

    How can you tell if the child is having an allergic reaction?

    Please Explain:

    Does your child have any special dietary needs?

    If yes, please list:

    Does your child have any habits (nail biting, thumb sucking, etc.) or other issues that we should be aware of?

    If yes, please explain:

    Does your child have any favorite foods?

    If yes, please list:

    Does your child have any favorite songs or games?

    If yes, please list:

    Does your child have any favorite toys or stuffed animals?

    If yes, please list:

    ATTACHMENT 5 - COMMUNICATIONS WITH PARENT/GUARDIANS

    Parents and guardians need to be informed of provisions in the Emergency Operations Plan this letter will provide the information that they need. A copy of the letter should be given to parents of newly enrolled children and at least once per year to all parents.

    [text_content show* "To the Parent (s)/Guardian (s) of"]

    * Name of child

    This letter is to ensure you of my concern for the safety and welfare of children attending Jeannie Peoples Child Care. The Emergency Operations Plan provides for response to all types of emergencies. Depending on the circumstance of the emergency, I will use one of the following protective actions:

    - Immediate evacuation - Students are evacuated to a safe area down the block from the facility in the event of a fire, etc.

    - In-place sheltering - Sudden occurrences, weather or hazardous materials related may dictate that taking cover inside the building is the best immediate response.

    - Evacuation - Total evacuation of the facility may become necessary if there is a danger in the area. In this case children will be taken to Curwensville Rescue Hose and Ladder located at Filbert Street, Curwensville, PA 16833.

    - Modified Operation — May include cancellation/postponement or rescheduling of normal activities. These actions are normally taken in case of a winter storm or building problems that make it unsafe for students (such as utility disruptions) but may be necessary in a variety of situations.

    In the event of an emergency, I will call you as soon as it is safe to do so. At that time, you will be instructed in what the next step will be.

    The form designating persons to pick up your child is included with this letter for you to complete an have returned tomorrow. This form will be sued every time your child is released. Please ensure that only those persons you list on the form attempt to pick up your child.

    I specifically urge you not to attempt to make different arrangements during an emergency. This will only create additional confusion.

    In order to assure the safety of your children, I ask your understanding and cooperation. If you have any questions or concerns, please feel free to talk with me about them.

    * Please sign

    * Today's Date

    I,

    authorize Jeannie People's Child Care

    to release my child(ren) to the person(s) designated. This is in consonance with Jeannie People's Family Child Care Emergency Operations Plan.

    NOTE: Parents and guardians should designate themselves as custodians. Friends, neighbors and other relatives may also be designated.

    1: *Child's Name

    2: Second Child's Name

    3: Third Child's Name

    4: Fourth Child's Name

    5: Fourth Child's Name

    * List #’s from above that are allowed for each

    * Designated Custodian Name

    * Designated Custodian Relationship

    * Designated Custodian Phone Number

    List #’s from above that are allowed for each

    Designated Custodian Name

    Designated Custodian Relationship

    Designated Custodian Phone Number

    List #’s from above that are allowed for each

    Designated Custodian Name

    Designated Custodian Relationship

    Designated Custodian Phone Number

    List #’s from above that are allowed for each

    Designated Custodian Name

    Designated Custodian Relationship

    Designated Custodian Phone Number

    List #’s from above that are allowed for each

    Designated Custodian Name

    Designated Custodian Relationship

    Designated Custodian Phone Number

    List #’s from above that are allowed for each

    Designated Custodian Name

    Designated Custodian Relationship

    Designated Custodian Phone Number

    List #’s from above that are allowed for each

    Designated Custodian Name

    Designated Custodian Relationship

    Designated Custodian Phone Number

    List #’s from above that are allowed for each

    Designated Custodian Name

    Designated Custodian Relationship

    Designated Custodian Phone Number

    * Your Signature

    * Relationship

    * Today's Date

    * Your Name

    * Address

    Address

    *Home Phone

    * Work Phone

    Cell Phone

    *Email

    FAMILY MEETING GUIDE DOCUMENTATION

    * Child's Name:

    * Name of Meeting Attendees:

    *Meeting Date:

    * Type of Meeting: (Note - Partnership = Partnership Meeting (45 days))

    Agenda for the meeting:

    Follow up Activities:

    We had the opportunity of getting to know each other on

    * Date of tour

    During this time, we toured the facility and met with Jeannie Peoples. We also discussed scheduling, required forms and received a copy of the Policy and Procedure Manual. We were given the meal times for the program. We also had the opportunity to discuss our child's likes and dislikes and previous child care experiences. We also shared any concerns about our child's developmental progress.

    * Your Name

    I have received a copy of this notice

    * Signature of parent

    * Date of sig

    INDIVIDUALIZED EDUCATION PLANS (IEP) & INDIVIDUALIZED FAMILY SERVICE PLANS (ISP)

    * Child's Name

    Your child's growth and development is measured with development assessments. If your child currently has an IEP/IFSP it would be beneficial to share a copy of this plan with me so we can work together to ensure that the guidelines are put into practice. You do not have to provide this information if you do not wish to do so.

    * Providing a copy of my child's IEP or IFSP

    * Signature

    * Date signed

    * Your Name

    IEP/IFSP Upload

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    Infant Feeding Scheduel

    Infant Feeding Scheduel

    I will provide breast milk or formula listed below to the staff to use for feeding my child while attending child care.

    Please list brand/type of formula or list breast milk or combination that you will be providing and you would like us to use when feeding your child. Also list if you prefer to supply water to mix formula (if sending powder) or would like us to use tap water. Please be sure to label with your child's name any supplies left at child care and any bottle that is brought herel.

    Breast MIlk

    We will not mix with tap water.

    List Brand of Formula

    Mix With Bottle Watter

    My Baby Prefers the Bottle (Choose One)

    My Child Typically Eats Every (Hrs)

    Inital if you Prefer we Feed on Demand

    How Often Does Child Eat

    How Many Ozs Does Child Eat at Feeding

    Parent/Guardian Sig

    Parent/Guardian Date

    If an existing client and need a change fill below, new parents skip this step

    Please Increase My Child to ___ Ounces at This Time

    Please Increase My Child to ___ Ounces at This Time

    Parent/Guardian Date

    Parent/Guardian Date

    Parent/Guardian Initial

    Parent/Guardian Initial

    Please Begin Feeding My Baby the Food That I Have Supplied at This Time

    Please Begin Feeding Table Food to My Child

    Parent/Guardian Date

    Parent/Guardian Date

    Parent/Guardian Initial

    Parent/Guardian Initial

    Immunization Exemption Letter

    *your name

    To Whom It May Concern:

    Re: Pennsylvania Vaccination Requirements - Religious Exemption

    We,

    *Your Name

    Being the Legal Guardians of

    of

    *Childs Name

    object to the Immunization

    Requirements as outlined by the Department of Health of the Commonwealth of Pennsylvania as defined in 28 PA. CODE CH.23 on the basis of a religious belief/strong moral or ethical conviction outlined in section 23.84 Exemption from Immunization.

    * Parent/Guardian Sig

    * Parent/Guardian Date

    23.84. Exemption from immunization. 28 PA. CODE CH.23

    Source: http://www.pacode.com/secure/data/028/chapter23/s23.84.html

    (a) Medical Exemption. Children need not be immunized if a physician or the physician's designee provides a written statement that immunization may be detrimental to the health of the child. When the physician determines that immunization is no longer detrimental to the health of the child, the child shall be immunized according to this subchapter

    (b) Religious Exemption. Children need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief.

    After your Health Care Professional has filled out, please upload Child Health Report & Special Health Care Plan forms to finish your packet. They are available to download and print under downloads menu. You can submit them now if you have them or submit them separately later by emailing them to info@lpchildcare.com

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