AIK Enrollment Packet

This packet contains the following documents:

• Instruction Sheet

• Health Information/Emergency and Identification Form

• Child’s Preadmission Health History

• Personal Rights

• Child Care Center Notification of Parents’ Rights

• Media & Photo Release/Release of Liability/Nut Policy/Permit of

Sunscreen

• Census Report

Step by Step Instructions for Completion

1. Download the packet from the Girls Inc. of the Island City website2. Save the file to your computer3. Enter the necessary information on all forms4. Save the file frequently and once you have finished entering all the information5. Print all six forms (exclude direction page)6. Sign each form where applicable7. Bring the completed and signed forms with you to in-person enrollment8. The Enrollment and Agreement forms will be given in-person at time of enrollment.

These are three-part forms that need to be filled out and signed. (Please see Enrollment

Schedule for dates, times, and locations.)

9. These eight forms and the non-refundable deposit will complete enrollment.10. Your child/children’s information will be placed on a waiting list in the event the

program is full

I

d©..?\ALAME.DA HEALTH INFORMATION a service of

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Girls Incorporated®

of the Island City

PLEASE PRINT ALL OF THE INFORMATION BELOW

Child's Last Name: _______________ _ First Name: ___________ Birthdate: ______ _ Age: ___ _

Special Medical Limitations: -----------------------------------------

Allergies to

Food:-------------------------------------------------

Medicine: ------------------------------------------------

other: ______________________________________________ _

Please List ALL medications (including OTC) taken by your child: ____________________________ _

Check all that apply Special Disabilities: D Learning D Developmental D Emotional D Visual D Hearing □ Mobility

D Other Special Needs:-----�---------------------------Parent/Guardian - Please read and sign: I give my permission to obtain all emergency medical or dental care prescribed by a duly licensed Physician (M.D.) Osteopath (D.O) or Dentist (D.D. S.) for my child. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the child named above� ---

M@O@i► Parent/Guardian Signat Date Dentist Name & Phone Number

Medical Insurance & Coverage Number Physician Name Physician's Phone Number

□ EMERGENCY AND IDENTIFICATION INFORMATION

School: ________________ _ School Year: 20 - 20

PLEASE PRINT ALL OF THE INFORMATION BELOW

Child's Last Name: ______________ First Name: ________ _ Birthdate: ____ _ Age: __ _

Parent/Guardian Name: _____________ _ Work Phone: ( __ ) ______ _ Home Phone: ( ___ )

Address: ________________ _ City: Zip Code: _____ Cell Phone: ( __ _

Parent/Guardian Name: _____________ _ Work Phone: ( __ ) ______ _ Home Phone: ( ___ )

Address: ________________ _ City: ______ _ Zip Code: _ ____ Cell Phone:( __ _

ALAMEDA SLAND KIDS

Grade: __ _

In addition to the parents/guardians, the following adults (18 years and older) are authorized to take this child from the facility. These names will also serve as emergency contacts. These contacts must be reachable and available for immediate pick-up or response. Name Phone Name Phone

1. ------------

2. ------------

(_)

(_)

3. ___________ _

4. ___________ _

i--J@•M�----,-,,--,--,-,-------------------Parent1Guardian Signature Date

Based on court documents on file at site

(_)

(_)

□ DO NOT RELEASE - My child should NEVER be released to: --------------;::::::::::::::::::::::�::::::::::::::::::::::::::::::::::::::::::::::::..::,-

D Parent/Guardian D Other: ________________ _ STAFF

USE ONLY

Initial Date

GlollC (4003 emeraencv) 4/3/17

DAILY ROUTINES (*For infants and preschool-age children only) - *Not Applicable for AIK

DEVELOPMENTAL HISTORY (*For infants and preschool-age children only) - *Not Applicable for AIK

STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY

CHILD’S NAME SEX BIRTH DATE

DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

DATE OF LAST PHYSICAL/MEDICAL EXAMINATION

FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME

MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME

IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?

BEGAN TALKING AT*MONTHS

TOILET TRAINING STARTED AT*MONTHS

WALKED AT*MONTHS

SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS

DOES CHILD HAVE FREQUENT COLDS? !! YES !! NO

WHAT TIME DOES CHILD GET UP?*

DOES CHILD SLEEP DURING THE DAY?*

DIET PATTERN:(What does child usuallyeat for these meals?)

ANY FOOD DISLIKES?

WORD USED FOR “BOWEL MOVEMENT”*PARENT’S EVALUATION OF CHILD’S HEALTH

PARENT’S EVALUATION OF CHILD’S PERSONALITY

HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?

HAS THE CHILD HAD GROUP PLAY EXPERIENCES?

DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)

WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?

REASON FOR REQUESTING DAY CARE PLACEMENT

PARENT’S SIGNATURE DATE

LIC 702 (8/08) (CONFIDENTIAL)

WORD USED FOR URINATION*

IS CHILD TOILET TRAINED?*!! YES !! NO

IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?

!! YES !! NO

IF YES, NAME OF DOCTOR: DOES CHILD TAKE PRESCRIBED MEDICATION(S)?

!! YES !! NOIF YES, WHAT KIND AND ANY SIDE EFFECTS:

IF YES, AT WHAT STAGE:* ARE BOWEL MOVEMENTS REGULAR?*!! YES !! NO

ANY EATING PROBLEMS?

WHAT IS USUAL TIME?*

BREAKFAST

LUNCH

DINNER

WHEN?* HOW LONG?*

WHAT ARE USUAL EATING HOURS?

BREAKFAST ________________________

LUNCH_____________________________

DINNER

WHAT TIME DOES CHILD GO TO BED?* DOES CHILD SLEEP WELL?*

HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF

PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:DATES

!! Chicken Pox

!! Asthma

!! Rheumatic Fever

!! Hay Fever

!! Diabetes

!! Epilepsy

!! Whooping cough

!! Mumps

!! Poliomyelitis

!! Ten-Day Measles(Rubeola)

!! Three-Day Measles(Rubella)

DATES DATES

CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING

DOES CHILD USE ANY SPECIAL DEVICE(S):

!! YES !! NO

DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?

!! YES !! NO

IF YES, WHAT KIND: IF YES, WHAT KIND:

NOT A

PPLIC

ABLE

FOR A

IK

NA NA NA

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Media/Photo ReleaseI, _________________________________, as enrolling parent or legal guardian, for ______________________ hereby authorize Girls Inc. of the Island City, doing business as Alameda Island Kids, its agents and others working for it or on its behalf to use my child's image/likeness/voice/ artwork/writing in still photos, slides, video productions, radio coverage, television coverage, interviews, testimonials, and/or any other media purposes, including Girls Inc. website, for promoting and representing Girls Inc. and its programs, and do hereby grant and convey unto Girls Inc. all rights, title, and interest in the above media including but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.

Enrolling Parent/Guardian Initials: ___________☐ I Decline the Media/Photo Release portion of this form.

Child’s Name (please print): _______________________________________ Original AIK Site: ______________

Enrolling Parent/Guardian Signature: _________________________________________ Date: ______________

Print Name: _____________________________________________________________

Peanut Butter & Nut PolicyDue to an increase in severe nut allergies, including airborne reactions, among the children in our care, peanut butter and all types of nuts will no longer be served at Alameda Island Kids. This is especially critical when sites combine for non-student days, breaks, and recesses. In order to maintain a safe environment and decrease the potential of high risk situations, parents are asked not to pack peanut butter or nuts of any kind in their child’s lunch or snack.

Enrolling Parent/Guardian Initials: __________

Liability Agreement ReleaseI, ____________________________ hereby authorize,as enrolling parent or legal guardian, for _____________to participate in Girls Inc. and Alameda Island Kids Programs. In consideration for this participation, I do hereby, for myself and my heirs and assigns, release and agree to indemnify and hold harmless Girls Incorporated of the Island City, its employees and volunteers from all liability, loss, claim, demand, action or cause of action which arises or may arise or be occasioned in any way by such participation. I also release and hold harmless Girls Inc. of the Island City, its employees and volunteers from all liability, loss or claim which may occur in transporting my child for the purposes of participating in any Girls Inc. activities.

Enrolling Parent/Guardian Signature: _________________________

Print Name: _____________________________ Date: ___________

Permit of SunscreenApplication and Use

For present and future skin protection, children may bring their own bottle of sunscreen. It will be labeled with their name and left at the center. This will allow your child to apply the sunscreen as needed.

• The first application should take place at home fromyour own supply and prior to sun exposure.

• If re-application is required, you will need to discusswith your child the plan for the best time of the day toapply the sunscreen for him or herself.

• Staff cannot take responsibility for schedule ofre-application.

• On-site outdoor activities may result in sun exposureand sunscreen would be advised.

Enrolling Parent/Guardian Initials: __________

AIK Staff Initial: ________ Date:________

a service of Girls Incorporated® of the Island City

Alameda Island Kids at ________________

School Census Report - School Year 20__ - 20__

This information will be kept anonymously and in

confidence. It will be used strictly for statistical data

reports to Girls Inc. National Organization and poten-

tial funders. Thank you for your help.

My Child’s Name: ____________________________________

Please mark all appropriate boxes.

AGE

6 11

7 12

8 13-15

9 16-18

10

MY CHILD QUALIFIES FOR

Free Lunch Reduced Lunch

FAMILY CONFIGURATION

Living with two parents

Living with mother only

Living with father only

Living with one parent at a time(joint custody)

Living with parent & step-parent

Living with neither parent (e.ggrandparent, foster parent, etc)

ETHNICITY

Multi-ethnic Filipino

Asian American

Black / African American

Native American

White / Caucasian

Hispanic/Latina

Pacific Islander

Other: ___________________________

PRIMARY LANGUAGE SPOKEN IN THE HOME

English Spanish

Farsi Mandarin

Tagolog Vietnamese

Other: ___________________________

RESIDENCE AREA

Alameda San Lorenzo

Oakland Livermore

Castro Valley Hayward

San Leandro Berkeley

Other: ___________________________

NUMBER LIVING IN HOUSEHOLD ________

ANNUAL HOUSEHOLD INCOME

Below $10,000 $10,000 to $15,000

$15,000 to $20,000 $20,000 to $25,000

$25,000 to $30,000 $30,000 to $40,000

$40,000 to $50,000 $50,000 to $60,000

$60,000 to $70,000 $70,000 to $80,000

$80,000 to $90,000 $90,000 to $100,000

$100,000 and above

ARE ANY IMMEDIATE FAMILY MEMBERS ACTIVE DUTY MILITARY PERSONNEL?

Yes No

PLEASE LIST ANY MEDICAL, PHYSICAL, OR EMOTIONAL CONDITIONS (INCLUDING DISABILITIES)

_________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________

ALAMEDA ISLAND KIDS

GIotIC (4003 census) 3/19/18

childs preadmission health history (1).pdfChild's Preadmission Health History - Parents ReportChild's Preadmission Health History - Physician's ReportMedical Consent and Excursion ReleaseConsent for Medical Emergency TreatmentChild's ID and Emergency InformationPersonal RightsHealth Screening for Classroom VolunteersTuberculosis Screening ReportChild Abuse Prevention PamphletPUB129 - Child Abuse PreventionNotification of Parents' RightsTransportation Liability ReleaseParent Obligations and AgreementCommittee Choice FormCommittee Chairpersons DescriptionsCommittee Members DescriptionsParents' Interest SheetScheduling FormChild Information Sheet

Special Medical Limitations: other: Please List ALL medications including OTC taken by your child: Check all that apply: D Other Special Needs: Dentist Name Phone Number: Medical Insurance Coverage Number: Physician Name: Physicians Phone Number: School: Grade: ParentGuardian Name: Work Phone: Home Phone: Address: City: Zip Code: Cell Phone: ParentGuardian Name_2: Work Phone_2: Home Phone_2: Address_2: City_2: Zip Code_2: 1_3: undefined_3: 3: undefined_4: 2_3: undefined_5: 4: undefined_6: DO NOT RELEASE My child should NEVER be released to: D Other: Food: Medicine: Check Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffText13: Text14: Cell Phone_2: 1: 2: Age: Text: Date1_af_date: Date2_af_date: Text1: Text2: Text3: Text4: Text5: Text6: Text7: Text8: Check Box13: OffText18: Check Box22: OffText26: Check Box30: OffText33: Check Box14: OffText19: Check Box23: OffText27: Check Box31: OffText34: Check Box15: OffText20: Check Box24: OffText28: Check Box32: OffText35: Check Box16: OffText21: Check Box25: OffText29: Text49: Text40: Text41: Text15: Text47: Text48: Text51: Text55: Text58: Text61: Text62: Text63: Text64: Text65: Text66: Text67: Text68: Text69: Text70: Text71: Text72: Date50_af_date: Text 6: Text 7: Date3_af_date: Original AIK Site: Date4_af_date: Text97: Text99: Text98: Text93: Text 93: PRINT THE ADDRESS OF THE FACILITY: Text94: Representative: Alameda Island Kids at: undefined: undefined_2: NUMBER LIVING IN HOUSEHOLD: EMOTIONAL CONDITIONS INCLUDING DISABILITIES 1: EMOTIONAL CONDITIONS INCLUDING DISABILITIES 2: EMOTIONAL CONDITIONS INCLUDING DISABILITIES 3: Emotional conditions 4: Emotional conditions 5: undefined_8: Check Box99: OffCheck Box98: OffCheck Box97: OffCheck Box9: OffCheck Box96: OffCheck Box95: OffCheck Box94: OffCheck Box93: OffCheck Box92: OffCheck Box91: OffCheck Box90: OffCheck Box89: OffCheck Box88: OffCheck Box87: OffCheck Box86: OffCheck Box85: OffCheck Box84: OffCheck Box83: OffCheck Box81: OffCheck Box79: OffCheck Box78: OffCheck Box77: OffCheck Box76: OffCheck Box74: OffCheck Box73: OffCheck Box72: OffCheck Box71: OffCheck Box70: OffCheck Box69: OffCheck Box68: OffCheck Box67: OffCheck Box66: OffCheck Box65: Offcheckbox64: OffCheck Box63: OffCheck Box62: OffCheck Box61: OffCheck Box60: OffCheck Box59: OffCheck Box58: OffCheck Box57: Check Box56: Check Box55: OffCheck Box54: OffCheck Box53: OffCheck Box52: OffCheck Box50: OffCheck Box49: OffCheck Box48: OffCheck Box47: OffCheck Box46: OffCheck Box45: OffDate6_af_date: Date7_af_date: Date5_af_date: PRINT THE NAME OF THE FACILITY: other2000: other2001: Check Box2000: OffCheck Box2001: OffCheck Box2002: Check Box2003: Check Box2004: OffCheck Box2005: OffCheck Box2006: OffCheck Box2007: OffCheck Box3000: OffCheck Box3001: OffCheck Box4000: OffCheck Box4001: OffCheck Box5000: OffCheck Box5001: OffCheck Box6000: OffText10: Text11: