Best of Boston 2017 - (857) 259-5211

Help · Find a School

Child Information Packet

Please complete the registration form and attach a photo of your child. All fields must be filled out completely in order to process registration.

Attach a Photo of Your Child Here

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Child's Information

Child's Name *

Date of Birth

Sex

Address

Street Address, City, State, Zip

Phone Number

Nickname (if any) and / or Identifying Markings

Enrollment Date

Child Lives With (Please Check One)

Both Parents

Mother

Father

Guardian

Additional Child Info

Primary Language

Height

Weight

Hair Color

Skin Color

Eye Color

Parent/Guardian Information

Parent/Guardian Name

Address

Street Address, City, State, Zip

Cell Phone

Employer

Parent/Guardian Name

Address

Street Address, City, State, Zip

Cell Phone

Employer

Parent's Marital Status

Married

Single

Divorced

Co-Habitating

Persons with legal custody: (Attach pertinent paperwork such as Court Order if a parent is not permitted to pick up the child.)

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Parent/Guardian Initial

Date

Emergency Contacts/Authorized Pick Up

The following people are authorized to pick up my child and also may be contacted in an emergency or illness in the event I cannot be reached.

Name

Home Number

Work Number

Cell/ Other Number

Relationship to child

Name

Home Number

Work Number

Cell/ Other Number

Relationship to child

Name

Home Number

Work Number

Cell/ Other Number

Relationship to child

Name

Home Number

Work Number

Cell/ Other Number

Relationship to child

Persons Not Authorized To Pick Up

Please note: Rock and Roll Daycare must have a copy of the legal custody order in order to deny pick up from a parent.

Name

Home Number

Work Number

Cell/ Other Number

Relationship to child

Name

Home Number

Work Number

Cell/ Other Number

Relationship to child

Name

Home Number

Work Number

Cell/ Other Number

Relationship to child

Name

Home Number

Work Number

Cell/ Other Number

Relationship to child

Parent/Guardian Initial

Date

About Your Child

Favorite toys, games and activities?

How does your child express ANGER or frustration?

Does your child have any special FEARS?

When your child is upset, what helps to comfort him/her?

How do you DISCIPLINE your child?

Special toy or blanket for NAP?

Special family situations, i.e. custody specifications, problems arising from situations, etc?

Anticipated ADJUSTMENT problems?

Any disorders/developmental (delay, advanced) diagnosed or suspected?

Your EXPECTATIONS of Rock and Roll Daycare:

Health Insurance

Health Insurance Coverage

Policy #

Parent/Guardian Name

Phone

Parent/Guardian Initial

First Aid and Emergency Medical Care Consent Form

Child's Name

Date of Birth

Child's Physician Name

Phone

Address

Child's Allergies

Chronic Health Conditions

Emergency Release Form

Consent to Emergency First Aid & Transportation

Parent/Guardian Initial

Date

Consent to Medical Care and Treatment

Parent/Guardian Initial

Date

Parent/Guardian Initial

Date

Child Emergency Medical Information

Child's Physician

Phone

Preferred Hospital

Phone

Insurance Company

Policy #

Medicaid

Medicaid Case #

Regular Medications

Blood Type

Food Allergies

Medicine Allergic to

Other Allergies

Individual Health Care Plan

Date

Authorization for Medication Administration

The parent/guardian of ________________________________ (Child’s name) ask that Rock and Roll Daycare give the following medication __________________________________________  (Name of medicine and dosage) at __________________________________ (Time/s) to my child, according to the Physician’s signed instructions on the lower part of this form.
Rock and Roll Daycare agrees to administer medication prescribed by a licensed health care provider. It is the parent/guardian’s responsibility to furnish the medication. The parent agrees to pick up expired or unused medication within one week of notification by staff.
Prescription medications must come in the original container labeled with: child’s name, name of medicine, time medicine is to be given, dosage, date medicine is to be stopped, and licensed health care provider’s name. Pharmacy name and phone number must also be included on the label.
Over the counter medication must be labeled with child’s name. Dosage must match the signed health care provider authorization, and medicine must be packaged in original container.
By signing this document, I give permission for my child’s health care provider to share information about the administration of this medication with Rock and Roll Daycare to administer medication.

Parent/Guardian Initial

Date

Physician Authorization to Administer Medication

Child's Name

Birth Date

Medication

Dosage

Route

To be given at the following time(s)

Special Instructions

Purpose of Medication

Side effects that need to be reported

Starting Date

Ending Date

License #

Phone Number

Date

Parent/Guardian Initial

Date

Health Care Plan

Severe Allergy Form

Child's Name

Birth Date

Weight

Treatment

Special Instructions

For health care provider to complete

Emergency Treatment - Severe Symptoms

Special Instructions

For health care provider to complete

Parent/Guardian Initial

Date

If Tuberculin Test Given

Date

Result

If Chest X-rayed

Date

Result

Surgery, Accidents, Illnesses, Chronic or Handicapping Problems

Date of Last Lead Screening

Immunizations

Up-to-date

See attached immunization record

Physical Findings

Include, if tested, vision and hearing

Next Well Child Visit

Per *AAP Guidelines

Age

*The AAP recommends that children from 0-12 years have health appraisal visits at: 2, 4, 6, 9, 12, 15, 18 and 24 months, and age 3, 4, 5, 6, 8, 10 and 12 years.

Date

Office Stamp

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Doctor's Address

Doctor's Telephone Number

Health History

Child's Name

Birth Date

Last test date

Vision

Hearing

Dentist

Any other members of your family with SERIOUS ILLNESS recently?

Any history of:

Asthma

Diabetes

Epilepsy

Developmental History & Background Information

Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child.

Developmental History

Age began sitting

Crawling

Walking

Talking

*Does your child pull up?

Yes

*Crawl?

Yes

*Walk with support?

Yes

Any speech difficulties?

Special words to describe needs

Language spoken at home

*Any history of colic?

*Does your child use pacifier or suck thumb? When?

*Does your child have fussy time? When?

How do you handle this time?

Health

Any known complications at birth?

Serious illnesses and/or hospitalizations

Special physical conditions, disabilities

Allergies

(i.e. asthma, hay fever, insect bites, medicine, food reactions)

Regular medications

Eating Habits

Does you child eat solid foods

Please inform us when your child transitions.

Special characteristics or difficulties

*If infant is on a special formula, describe its preparation in detail

Favorite foods

Foods refused

*Is your child fed in

Lap

High chair

*Does your child eat with

Spoon

Fork

Hands

Sleeping Habits

What does your child sleep in

Crib / Pack N Play

Bed

With Parent

Other

Does your child become tired or nap during the day (include when and how long)?

When does your child go to bed at night?

When does your child wake up in the morning?

Describe any special characteristics or needs (stuffed animal, story, mood on waking etc)

Social Relationships

How would you describe your child?

Previous experience with other children/day care

Reaction to strangers

Able to play alone?

Fears (the dark, animals, etc.)

How do you comfort your child?

Daily Schedule

Please describe your child’s schedule on a typical day. For infants, please include awakening, eating, time out of crib/bed, napping, toilet habits, fussy time, night bedtime, etc.

Is there anything else we should know about your child?

Tooth Brushing

Would you like us to brush your child’s teeth each day with toothpaste?

Yes

Parent/Guardian Initial

Date

Media Authorization

Checkboxes

I authorize Rock and Roll Daycare to photograph my child(ren). I understand that such photographs may be used for promotional materials including, but not limited to: brochures, newsletters, bulletin boards, and website. No last name or specific identifying information will be included in any sort of material. If I do not want any photo on the promotional materials for any reason, I understand Rock and Roll Daycare will gladly remove it as soon as possible.

I do not authorize Rock and Roll Daycare to photograph my child(ren).

Parent/Guardian Initial

Date

Research Study Authorization

Checkboxes

I authorize my child to participate in any research study, for educational purposes only, which is conducted on the premises of Rock and Roll Daycare by a reputable collegiate organization, such as Harvard University, MIT, Boston University, or any other accredited university in good standing . I understand and agree that all research studies conducted as part of this agreement will be based on observation of children around areas such as language, music, cognition, and mobility. I understand and agree that I will be contacted by email prior to the commencement of any study, and may elect to decline my child’s participation in any study.

I do not authorize Rock and Roll Daycare to to allow my child(ren) to participate in research studies on the premises .

Additionally, I understand that Rock and Roll Daycare may elect to provide internships for early childhood candidates and Montessori certificate candidates. These interns will be on site for a limited term, and will undergo the requirements of a satisfactory CORI and BRC prior to conducting work with children.

Parent/Guardian Initial

Date

All Topical Products Authorization

Parent/Guardian Initial

Date

Request for Reference

We hope that you find Rock and Roll Daycare to be a delightful place for your child and that you are pleased with the services we provide. We would greatly appreciate it if we may offer you as a reference to share with prospective clients. Please indicate below whether you would be willing to be contacted via telephone, or if you are willing to provide a letter of reference.

Checkboxes

I grant Rock and Roll Daycare permission to offer perspective clients my telephone number for reference purposes.

Please do not give out my telephone number.

I prefer to provide Rock and Roll Daycare with a written letter of reference to offer to prospective clients.

I grant Rock and Roll Daycare permission to display my letter of reference on Rock and Roll Daycare website (if applicable).

My first and last name may be printed on the website.

Please only print my first name.

Parent/Guardian Initial

Date

Rock and Roll Daycare Contract

THE FOLLOWING CONTRACT IS MADE BETWEEN:

Mother/Guardian

Father/Guardian

Facility Location (Choose One)

East Cambridge (535 Cambridge St.)

Lechmere (527 Cambridge St.)

Central Square (166 Prospect St.)

Broadway (366b Broadway)

Payment

New Family: At this time, your first month of tuition and a non-refundable deposit of two weeks tuition is due. The deposit will be applied towards the last two weeks of childcare, and seven days grace period will be given to complete registration/medical forms. Current Family: At this time, your &75.00 Re-Registering fee will process in conjunction with the following tuition payment.

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Payment Schedule. All payments should be received by automatic electronic Green Payment Processor. Payments will be automatically processed on the 23rd business day of each month (ex. October 23rd for November Tuition). If payment is not received at this time, your child’s enrollment may be suspended and you will be financially responsible to provide full payment for the current month prior to returning to in good standing.

Signatures

By signing below the parent(s)/guardian(s) are agreeing to abide by the policies set forth in the Policy Handbook. The provider may amend the Policy Handbook by giving a new copy of the changed Policy Handbook two (2) weeks prior to the effective date.

Signature

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Clear

Parent/Guardian Signature

Date

Best of Boston 2017 - (857) 259-5211

Help · Find a School

Child Information Packet

Uploading Files. Please Wait.

Child's Information

Additional Child Info

Parent/Guardian Information

Emergency Contacts/Authorized Pick Up

Persons Not Authorized To Pick Up

About Your Child

Health Insurance

First Aid and Emergency Medical Care Consent Form

Emergency Release Form

Child Emergency Medical Information

Off-Site & Transportation Permission

Authorization for Medication Administration

Physician Authorization to Administer Medication

Health Care Plan

Health Evaluation Form

If Tuberculin Test Given

If Chest X-rayed

Health History

Illness

Last test date

Developmental History & Background Information

Developmental History

Health

Eating Habits

Toilet Habits

Sleeping Habits

Social Relationships

Daily Schedule

Tooth Brushing

Media Authorization

Research Study Authorization

All Topical Products Authorization

Request for Reference

Rock and Roll Daycare Contract

Payment

Signatures

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