Please be sure to complete the following checklist. · Other relative / kinship care: Dual parent, married Other relative / kinship care: Single parent, female head of house Other

REGISTRATION PACKETYOUTH DEVELOPMENT

Last modified 07/04/2019

REGISTRATION PACKETPRESCHOOL ACADEMY

Please be sure to complete the following checklist.

I have read, completed and signed the following pages: ¨ Registration Form ¨ Demographic Information Form ¨ Draft Authorization Form ¨ Pick Up Authorization Form

¨ On this page, I have included TWO emergency contacts of people OUTSIDE the household ¨ Parent Agreement Form ¨ Release and Waiver of Liability and Indemnity Agreement ¨ PCLB Emergency Medical Release

¨ This page has been notarized ¨ PCLB Child’s Enrollment Record (front and back)

¨ On this page I have included full doctor and dentist information ¨ PCLB Food Experience Permission Form ¨ Influenza Brochure (front and back)

Speer and Lealman YMCA Preschool Academies only: ¨ Childcare Food Program Free and Reduced-price meal application ¨ Florida Dept of Health Child Care Food Program Child Participation Form

Lealman YMCA Preschool Academy only: ¨ Authorization and Consent for Disclosure, Receipt and Use of Confidential Information by the Juvenile

Welfare Board of Pinellas County ¨Written Statement of Purpose(s) for Collection of Social Security Number for Recipients of JWB-funded

Programs and Services ¨Child Care Food Program Infant Feeding Form

Additional Items: ¨ I have included all relevant court-ordered paperwork as outlined in the Preschool Academy Parent Manual ¨ I have included a copy of my Driver’s License or other state-issued identification ¨ I have included updated physical and immunization records



Note: YMCA Preschool Academies provide childcare and educational services year-round. The dates below reflect only the 2019-2020 school year and summer.

2019August 13 First Day of VPKSeptember 2 Closed - Labor DayNovember 25 - 27 No VPK *November 28 - 29 Closed - ThanksgivingDecember 23 No VPK *December 24 - 25 Closed - ChristmasDecember 26 - 30 No VPK *December 31 Closed - New Year’s Eve

2020January 1 Closed - New Year’s DayJanuary 2 - 3 No VPK *January 20 Closed - Martin Luther King Jr. DayMarch 16 - 20 No VPK *April 10 Closed - Professional DevelopmentMay 20 & 21 VPK Graduations

May 20 at 9:00AM at Lealman YMCA Preschool AcademyMay 20 at Noon at Speer YMCA Preschool AcademyMay 21 at 9:00AM at Bardmoor YMCA Preschool Academy

May 21 Last Day of VPKMay 22 Optional Day for VPK Students **May 25 Closed - Memorial DayMay 26 - 29 No VPK *June 1 Summer Program BeginsJuly 4 Closed - Independence DayAugust 6 Last Day of Summer ProgramAugust 7 Closed - Professional Development

* Indicates non-VPK instruction weeks; Attendees will be charged the full preschool tuition rate.

** On May 22, 2020 VPK students may attend (although VPK has ended) for only $25.00.

Dates to Remember Payment Draft Dates

PRESCHOOL DATES

Draft Date Dates Covered8/9/19 8/12/19 - 8/16/198/16/19 8/19/19 - 8/23/198/23/19 8/26/19 - 8/30/198/30/19 9/2/19 - 9/6/199/6/19 9/9/19 - 9/13/199/13/19 9/16/19 - 9/20/199/20/19 9/23/19 - 9/27/199/27/19 9/30/19 - 10/4/1910/4/19 10/7/19 - 10/11/1910/11/19 10/14/19 - 10/18/1910/18/19 10/21/19 - 10/25/1910/25/19 10/28/19 - 11/1/1911/1/19 11/4/19 - 11/8/1911/8/19 11/11/19 - 11/15/1911/15/19 11/18/19 - 11/22/1911/22/19 * 11/25/19 - 11/29/1911/29/19 12/2/19 - 12/6/1912/6/19 12/9/19 - 12/13/1912/13/19 12/16/19 - 12/20/1912/20/19 * 12/23/19 - 12/27/1912/27/19 * 12/30/19 - 1/3/201/3/20 1/6/20 - 1/10/201/10/20 1/13/20 - 1/17/201/17/20 1/20/20 - 1/24/201/24/20 1/27/20 - 1/31/201/31/20 2/3/20 - 2/7/202/7/20 2/10/20 - 2/14/202/14/20 2/17/20 - 2/21/202/21/20 2/24/20 - 2/28/202/28/20 3/2/20 - 3/6/203/6/20 3/9/20 - 3/13/203/13/20 * 3/16/20 - 3/20/203/20/20 3/23/20 - 3/27/203/27/20 3/30/20 - 4/3/204/3/20 4/6/20 - 4/10/204/10/20 4/13/20 - 4/17/204/17/20 4/20/20 - 4/24/204/24/20 4/27/20 - 5/1/205/1/20 5/4/20 - 5/8/205/8/20 5/11/20 - 5/15/205/15/20 5/18/20 - 5/22/205/22/20 5/25/20 - 5/29/205/29/20 ** 6/1/20 - 6/5/206/5/20 6/8/20 - 6/12/206/12/20 6/15/20 - 6/19/206/19/20 6/22/20 - 6/26/206/26/20 6/29/20 - 7/3/207/3/20 7/6/20 - 7/10/207/10/20 7/13/20 - 7/17/207/17/20 7/20/20 - 7/24/207/24/20 7/27/20 - 7/31/207/31/20 8/3/20 - 8/7/20



REQUIRED INFORMATION

CHILD’S Full Legal Name: Gender: □ Male □ Female

CHILD’S Preferred First Name: Date of Birth: / /

Home Address:

City: State: Zip:

Home Phone:

SPEER YMCA PRESCHOOL ACADEMY REGISTRATION FORM

Please PRINT CLEARLY and complete all the information below so we can accurately register your child without delay.

PARENT / GUARDIAN Name:

Place of Employment: Date of Birth: / /

Home Phone: Cell Phone: Work Phone:

Contact Email:


Place of Employment: Date of Birth: / /


Contact Email:

We will not disclose email addresses for any non-related YMCA use.

Have you applied for or been approved for YMCA financial aid / assistance? □ Yes □ No

Does your child have a School Readiness Scholarship from Early Learning Coalition? □ Yes □ No

Are you or your spouse employed by Pinellas County School Board? □ Yes □ No

Are you or your spouse employed by the YMCA? □ Yes □ No

Weekly Fee (draft only) - Please check one:

□ Age 2: $145.00 per week □ Ages 3 - 5: $135.00 per week

Registration Fee: $40 per family

YMCA Members: Save $16 per week on all rates listed above

During camp weeks, Member and Non-Member rates will apply. The rates above are based on the full fee amount. Financial assistance or subsidy will be prorated accordingly.

By signing below, I verify the following:• I understand and accept the payment process.• I understand that there will be a $25.00 non-sufficient funds fee for returned payments. • All information provided to the YMCA of Greater St. Petersburg is complete and accurate.

INITIAL I have received a copy of the YMCA Parent Manual.

PARENT / GUARDIAN Signature: Date: / /

Packet received by: Today’s Date: / /

School Attending: Child’s Start Date: / /

Weekly fee: $ Subsidy amount: $ or %

STAFFUSEONLY



Race:□ African American□ American Indian / Alaska Native

□ Asian□ Asian Indian□ Black

□ Multiracial□ Pacific Islander □ White / Caucasian

□ Other: □ Decline to Answer









Ethnicity: □ Chinese□ Cuban□ Filipino

□ Guamanian or Chamorro□ Japanese□ Korean

□ Mexican / Mexican American / Chicano□ Native Hawaiian□ Puerto Rican

□ Vietnamese□ Other: □ Decline to Answer









Student ID or Social Security Number: Foster Child: □ Yes □ No Lunch Status: □ Full □ Free □ Reduced

Education Level:□ Some High School□ High School Diploma / GED

□ Technical School□ Some College□ Associate Degree

□ Bachelor’s Degree□ Master’s Degree□ Doctorate Degree

□ Decline to answer

Education Level:□ Some High School□ High School Diploma / GED

□ Technical School□ Some College□ Associate Degree

□ Bachelor’s Degree□ Master’s Degree□ Doctorate Degree

□ Decline to answer

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Composition:□ Dual parent: Married□ Dual parent: Non-married, female head of house□ Dual parent: Non-married, male head of house□ Single parent: Female head of house□ Single parent: Male head of house

□ Other relative / kinship care: Dual parent, married□ Other relative / kinship care: Single parent, female head of house□ Other relative / kinship care: Single parent, male head of house□ Other non-relative care□ Decline to answer

Size: adults & children under age 18

Please estimate the gross yearly income your HOUSEHOLD receives from all sources BEFORE taxes - including income from jobs, Temporary Assistance for Needy Families (TANF), child support, alimony, etc. $ □ Weekly □ Bi-weekly □ Monthly □ Yearly □ Decline to answer

DEMOGRAPHIC INFORMATION FORM

REQUIRED INFORMATIONThe information collected here allows us to report general information about program participants and provide quality programs.

IMPORTANT: Your responses on this page DO NOT influence any scholarships or subsidies you may receive, or your child’s ability to participate in YMCA programs.




Childcare Location

Child’s Name

Draft Amount$

$

$

$

DRAFT AUTHORIZATION FORM

By signing below, I understand the following:• Automatic credit or debit card drafts will occur every week and will constitute prepayment for the upcoming week of childcare.• YMCA of Greater St. Petersburg reserves the right to suspend service if an account cannot be debited.• It is my responsibility to notify the YMCA in writing if my credit or debit card expires or my account information changes in any way -

including billing address changes.• If any charge is not honored by my financial institution, for any reason, I am still responsible for the total payment due, as well

as a returned payment service charge of $25 assessed by the YMCA of Greater St. Petersburg.• I hereby authorize my bank or credit card to honor monthly automatic drafts by the YMCA of Greater St. Petersburg on my account for

program payment. When the bank honors the draft by charging my account, notation on my statement shall constitute my receipt for payment. This authority is to remain in effect until revoked by me in writing.

• We do not accept call-in payments.

CARDHOLDER Signature: Date: / /


Home Address:

City: State: Zip:


Contact Email:

Please PRINT CLEARLY and complete all the information below so we can accurately register your child without delay.

Credit / Debit Card Number: Security Code:

Expiration Date: / □ Visa □ Mastercard □ Discover □ American Express

Name as it appears on the card:

Billing Address:

City: State: Zip:

PAYMENT INFORMATION

CONFIDENTIAL INFORMATION

Verified by: Today’s Date: / /

STAFFUSE

ONLY



CHILD’S Full Legal Name: Grade / Group:

PARENT / GUARDIAN Name: Phone:

Are copies of custody / restraining papers on file for your child? □ Yes □ No

Who has authorization to change, add and delete persons authorized for pick up?

PICK UP AUTHORIZATION FORM

Please include TWO emergency contacts of people OUTSIDE the household with addresses.

EMERGENCY CONTACT: Relationship:

Home Address:

City: State: Zip:


EMERGENCY CONTACT: Relationship:

Home Address:

City: State: Zip:


Phone: Staff Initials: Date: / /










EMERGENCY CONTACT INFORMATION

AUTHORIZED FOR PICK UPThe following people are authorized to pick up this child:



PAYMENT AGREEMENT (Does not apply to free programs including the Faith-Based Literacy Program and YMCA Reads!)• Due Date and Auto-Draft Schedule: Your weekly fee is due to the YMCA on the Friday prior to the week your child will be attending the program. Weeks are

not prorated. Auto-drafted payments occur weekly and your credit or debit card will be drafted at set intervals as outlined in this packet. Note that drafts will be drawn on the due date prior to service as prepayment for childcare. Please notify us of card number or expiration date changes.

• Paying by Money Order: Money orders are only accepted at Childs Park YMCA and Harbordale YMCA. If you are paying by money order, to ensure that your payment is correctly recorded in our system, please indicate the child’s full name and childcare location.

• Late Payment Fee: If your payment is not received by the designated due date, you will be charged a late fee of $2.00 per day. Your child may not attend the program until payment has been received and your child may lose their spot.

• Late Pick Up Fee: If you are late picking up your child, you will be charged a late pick up fee of $1.00 per minute, per child.• Insufficient Fund Fee: You will be notified if a payment is denied due to insufficient funds or for any other reason. There is a $25.00 insufficient fund fee and

payment is expected immediately. • Outstanding Balances: If you have any outstanding balances due to the YMCA of Greater St. Petersburg, they must be paid in full prior to registration.

I understand that I am responsible for paying for all YMCA fees. INITIAL

CANCELLATION POLICY If at any time your child needs to be withdrawn from the program, you must present a written notice two weeks in advance. INITIAL

VACATION POLICY (Does not apply to Faith-Based Literacy Program or YMCA Reads!)Each family will receive one week of vacation per school calendar year; all five days must be taken consecutively. Per absence requirement, the vacation policy does not apply to subsidized care families (ELC). Not available for school-age all-inclusive plan. Preschool vacation weeks are calculated based on a full calendar year.INITIAL

DISCIPLINE AND EXPULSION POLICYIn keeping with the YMCA mission and character values of caring, honesty, respect and responsibility, appropriate behavior is expected of all program participants AND parent / guardians. Respectful interactions with other participants and staff are at the core of the Y mission and essential to having a successful experience for all. Behavior that conflicts with these values will be addressed in a nature appropriate to the disruptive and / or unsafe behavior and is at the discretion of Y staff and leadership. If behavior is significant, you and your child might be asked to meet with the program director or executive director. Based on the behavior exhibited, the following sequence is referenced:

1. Verbal warning and documentation2. Written warning and documentation3. 1, 3 or 5 day suspension from the program4. Termination from the program

INITIAL

PHOTO RELEASEI give permission for photographs of my child to be used by the YMCA of Greater St. Petersburg for promotional and / or educational purposes. I realize that neither my child nor I will receive any compensation of any kind for use of the photographs.INITIAL

DISCLAIMERThe YMCA of Greater St. Petersburg does not discriminate on the basis of race, religion, gender, creed or socioeconomic status. Financial assistance is available to those who qualify. Please ask for a scholarship assistance application if you would like to apply for a scholarship for your child (does not apply to free programs). Failure to fill this form out accurately may result in a charge of incorrect fees. A scholarship application must be completed and approved prior to receiving financial assistance. Please complete each section in its entirety to ensure appropriate charges. If you receive government subsidy (ELC), your signature indicates that you understand that the correct paperwork must be turned in and you will adhere to the attendance policy set by the funding agency.INITIAL

• I give permission for my child to attend all YMCA activities and field trips.• I understand that the YMCA of Greater St. Petersburg does not carry accident insurance.• I give permission for the center to consult my child’s physician or dentist in case of an emergency if I cannot be reached.• I realize that the responsibility for payment on an injury that requires medical care is mine.

INITIAL


PARENT AGREEMENT FORM

NOTE: In extreme cases your child may be suspended or terminated from the program (e.g. a violent act against another child or staff member would be considered extreme). Dismissal from the program for disciplinary reasons could result in permanent removal from all YMCA programs.



RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN POTENTIALLY DANGEROUS ACTIVITIES. YOU ARE AGREEING THAT, EVEN IF THE YMCA OF GREATER ST. PETERSBURG USES REASONABLE CARE IN PROVIDING THESE ACTIVITIES, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THESE ACTIVITIES BECAUSE THERE ARE CERTAIN INHERENT DANGERS WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM THE YMCA OF GREATER ST. PETERSBURG IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THESE ACTIVITIES. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND YMCA OF GREATER ST. PETERSBURG HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.

In consideration for being permitted to utilize the facilities, services and programs of the YMCA for any purpose, including but not limited to observation or use of facilities or equipment, or participation in any program affiliated with the YMCA, without respect to location, the undersigned, for himself or herself and any personal representatives, heirs and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgment that such premises and all facilities and equipment thereon and such affiliated programs have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation.

IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE, INCLUDING BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY PROGRAM AFFILIATED WITH THE YMCA, WITHOUT RESPECT TO LOCATION, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees and agents (hereinafter referred to as “releasees”) from all liability to the undersigned, his personal representatives, assigns, heirs and next of kin for any loss or damage and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releasees or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein, or participating in any program affiliated with the YMCA, without respect to location.

2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned in, upon, or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releasees or otherwise.

3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to negligence of releasees or otherwise while in, about, or upon the premises of the YMCA and / or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA.

THE UNDERSIGNED further expressly agrees that the forgoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Florida and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THIS RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.




FC-0003 Sample (7/30/13)

EMERGENCY MEDICAL RELEASE

This form must contain only one child’s name, and be the original notarized form.

A new notarized form is required when there is a change in legal guardianship.

Please Print Information

Child’s Full Name: Birthdate:

Allergies:

Medicines Routinely Taken:

Name of Custodial Parent(s)/Legal Guardian(s):

Address: Street Address (number, apartment #, street) City State Zip Code

Home Telephone Cell Telephone Work Telephone

Family Physician’s Name/Health Care Resource:

Address: Street Address (number, apartment #, street) City State Zip Code

Telephone ( )

Hospital Preference: Name City

Medical Insurance Company:

Policy #: Expiration Date:

Emergency Contact (if custodial parent/guardian cannot be reached):

Address: Street Address (number, apartment #, street) City, State, Zip Code

Home Telephone Cell Telephone Work Telephone

Sign in the presence of the Notary. I hereby give my consent to any emergency facility and physician to administer necessary treatment to my child

, in the event of an emergency at which time (Child’s Full Name)

I cannot be reached. I give consent to transport by ambulance if situation warrants it.

Signature of Custodial Parent/Legal Guardian (Affiant) STATE OF FLORIDA COUNTY OF

The foregoing instrument was acknowledged before me on 20 (Month) (Day) (Year)

by , who is personally known to me or who has (Name of Affiant) SEAL OF NOTARYproduced as identification. (Type of Identification)

Signed: (Signature of Notary)


Last modified 07/04/2019C-0030 Required (Rev 4/18)

DIRECTOR’S USE ONLY Date enrolled CHILD'S ENROLLMENT RECORD

Child's full legal name First Middle Last Nickname Date of Birth_________________________ Sex__________

Primary Hours of Care From_________To_____________ Days of Week in Care______________________

Child’s Physical Address Street Address (number, apartment #, street) City State Zip Code

Family Information: Child Lives with_____________________________

Parent’s Name_______________________________ Parent’s Name__________________________________ Address:_____________________________________Address_______________________________________ Home Phone:_________________________________Home Phone:___________________________________ Employer:____________________________________Employer:______________________________________ Address:_____________________________________Address:_______________________________________ ____________________________________________ ______________________________________ Work Phone______________Cell_________________Work Phone_____________Cell____________________ Custody: Mother______ Father______ Both_________ Other_________ Name____________________ Emergency Contacts: Child will be released only to the custodial parent or legal guardian and the persons listed below. The following people will also be contacted and are authorized to remove the child from the children’s center in case of illness, accident or emergency, if for some reason the custodial parent(s) or legal guardian(s) cannot be reached: Name

Home Phone Cell Phone

Address Street Address (number, apartment #, street) City State Zip Code

Name

Home Phone Cell Phone


Please use additional sheet of paper to list name, address and phone number of any other people

authorized to pick the child up.

CONTINUED ON BACK


Last modified 07/04/2019C-0030 Required (Rev 4/18)

CHILD'S ENROLLMENT RECORD (Back Page)

Medical Information: Child's Physician/Health Resource

Telephone Number


Hospital Preference

Name of Dentist Telephone

Address Street Address (number, apartment #, street) City State Zip Code Emergency Care Plan instructions (if applicable) ________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MISCELLANEOUS INFORMATION

List all known allergies

List all identifying scars, birthmarks, skin discolorations

Special medical or dietary needs of child

List any areas of concern

My signature below verifies that: I give permission to consult the child's physician/health resource listed above in case of emergency if parent/legal guardian cannot be reached. I have received a copy of the “Know Your Child’s Children’s Center” brochure, a copy of the children’s center discipline and expulsion policies. I was notified that the snacks/meals served daily are: □Breakfast □AM Snack □Lunch □PM Snack □Dinner Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate. I hereby grant permission for the staff of this facility to have access to my child’s records. Signature of Custodial Parent or Legal Guardian Date



Food Experience Permission Form

I give permission for my child _________________________________ to participate in

food related activities.

Please check one of the following:

___________My child DOES NOT have a food allergy or dietary restriction.

___________My child DOES have a food allergy or dietary restriction. He or she may

participate, but may not eat or handle the following items (please list below)

____________________________________________________________________________________________________________________________________________

___________My child DOES have a food allergy or dietary restriction. He or she may

not participate in activities.

_________________________________ ___________________________

Parent Signature Date

C- 1050 Sample Form PCLB 12/13



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pare

nt’s

role

in q

ualit

y ch

ild c

are

is v

ital:

I

nqui

re a

bout

the

qual

ifica

tions

and

ex

perie

nce

of c

hild

car

e st

aff,

as w

ell a

s st

aff

turn

over

.

Kno

w th

e ch

ildre

n’s

cent

er p

olic

ies

and

proc

edur

es.

C

omm

unic

ate

dire

ctly

with

car

egiv

ers.

Vis

it an

d ob

serv

e th

e ch

ildre

n’s

cent

er.

P

artic

ipat

e in

spe

cial

act

iviti

es, m

eetin

gs, a

nd

conf

eren

ces.

Tal

k to

you

r chi

ld a

bout

thei

r dai

ly

expe

rienc

es in

the

child

ren’

s ce

nter

.

Arr

ange

alte

rnat

e ca

re fo

r a s

ick

child

.

F

amilia

rize

your

self

with

the

child

car

e st

anda

rds

used

to li

cens

e th

e ch

ildre

n’s

cent

er.

PIN

ELLA

S C

OU

NTY

C

HIL

DR

EN’S

CEN

TER

S

GEN

ERA

L IN

FOR

MA

TIO

N

Fo

r a li

stin

g of

chi

ldre

n’s

cent

ers,

con

tact

211

Ta

mpa

Bay

Car

es a

t 2-1

-1.

For a

n ap

poin

tmen

t to

revi

ew a

chi

ldre

n's

cent

er fi

le o

r to

file

a co

mpl

aint

con

tact

the

Chi

ld C

are

Lice

nsin

g Pr

ogra

m a

t (72

7) 5

07-

4857

. Fo

r fur

ther

info

rmat

ion

abou

t chi

ld c

are

in

Flor

ida

or to

vie

w c

hild

ren’

s ce

nter

insp

ectio

n re

ports

, vis

it th

e w

ebsi

te:

MyF

LFam

ilies.

com

/Chi

ldC

are

Our

mis

sion

is to

pro

tect

, pro

mot

e &

impr

ove

the

heal

th o

f all

peop

le in

Flo

rida

thro

ugh

inte

grat

ed

stat

e, c

ount

y an

d co

mm

unity

effo

rts.

The

stat

ewid

e to

ll-fre

e te

leph

one

num

ber f

or

repo

rting

chi

ld a

buse

is 1

-800

-96

ABU

SE

(1

-800

-962

-287

3).

Rep

orts

of s

uspe

cted

and

ac

tual

cas

es o

f chi

ld p

hysi

cal a

buse

, sex

ual

abus

e, a

nd n

egle

ct re

ceiv

ed th

roug

h th

e Ab

use

Reg

istry

num

ber a

re re

ferr

ed to

the

Pine

llas

Cou

nty

Sher

iff’s

Dep

artm

ent f

or

inve

stig

atio

n.

KN

OW

YO

UR

C

HIL

D’S

C

HIL

DR

EN'S

C

ENTE

R

N

urse

ry S

choo

l

K

inde

rgar

ten

D

ay N

urse

ry

Sch

ool A

ge C

ente

r

P

INE

LLA

S C

OU

NTY

LIC

EN

SE

BOA

RD

fo

r Chi

ldre

n’s

Cen

ters

and

Fa

mily

Chi

ld C

are

Hom

es

87

51 U

lmer

ton

Roa

d, S

uite

200

0 La

rgo,

FL

3377

1 Te

leph

one

727-

507-

4857

w

ww

.pcl

b.or

g

Th

e C

hild

Car

e Li

cens

ing

Pro

gram

and

its

serv

ices

ar

e fu

nded

by

the

Juve

nile

Wel

fare

Boa

rd,

the

Flor

ida

Dep

artm

ent o

f Chi

ldre

n an

d Fa

mily

Ser

vice

s an

d th

e Fl

orid

a D

epar

tmen

t of

H

ealth

, P

inel

las

Cou

nty.

C

-000

2 (R

ev.0

8/16

)



PIN

ELLA

S C

OU

NTY

CH

ILD

REN

’S

CEN

TER

S LI

CEN

SIN

G S

TAN

DA

RD

S Th

is c

hild

ren’

s ce

nter

has

met

regu

latio

ns fo

und

in

Lice

nsin

g R

egul

atio

ns G

over

ning

Pin

ella

s C

ount

y C

hild

ren’

s C

ente

rs.

A

val

id te

mpo

rary

per

mit

or li

cens

e, w

hich

bea

rs th

e di

stin

ctiv

e se

als

of P

inel

las

Cou

nty

and

the

Flor

ida

Dep

artm

ent o

f Chi

ldre

n an

d Fa

mily

Ser

vice

s, is

po

sted

in a

con

spic

uous

pla

ce w

ithin

the

cent

er.

A va

lid te

mpo

rary

per

mit

or li

cens

e w

ill a

lso

incl

ude:

ef

fect

ive

and

expi

ratio

n da

tes,

a li

cens

e nu

mbe

r, ca

paci

ty a

nd a

ges

of c

hild

ren

in c

are.

A L

ICEN

SED

CH

ILD

REN

’S C

ENTE

R M

UST

:

Adh

ere

to it

s lic

ense

d ca

paci

ty a

t all

times

.

Pos

t a s

ched

ule

of d

aily

act

iviti

es.

H

ave

first

aid

and

em

erge

ncy

proc

edur

es, a

nd

post

eva

cuat

ion

diag

ram

s in

eac

h ro

om.

K

eep

accu

rate

, cur

rent

dai

ly a

ttend

ance

reco

rds

and

docu

men

t a v

isua

l sw

eep

of th

e en

tire

prem

ises

at t

he e

nd o

f eac

h da

y.

P

rovi

de p

aren

t(s) o

r leg

al g

uard

ian(

s) a

cces

s to

th

e ch

ildre

n’s

cent

er d

urin

g no

rmal

hou

rs o

f op

erat

ion.

Rep

ort s

uspe

cted

chi

ld a

buse

to th

e st

atew

ide

toll-

free

tele

phon

e nu

mbe

r.

Pro

vide

a p

erm

issi

on fo

rm fo

r par

ent(s

) or l

egal

gu

ardi

an(s

) to

allo

w th

e ce

nter

to a

dmin

iste

r m

edic

atio

n as

nec

essa

ry.

D

ocum

ent r

equi

red

info

rmat

ion

whe

n ad

min

iste

ring

med

icat

ion.

Doc

umen

t acc

iden

ts a

nd in

cide

nts

and

obta

in

pare

nt’s

, leg

al g

uard

ian’

s or

aut

horiz

ed p

ick-

up

pers

on’s

sig

natu

re(s

).

Mai

ntai

n ve

hicl

es in

saf

e co

nditi

on if

tran

spor

tatio

n is

pro

vide

d.

O

btai

n pa

rent

’s o

r leg

al g

uard

ian’

s pe

rmis

sion

be

fore

tran

spor

ting

child

ren.

Mai

ntai

n co

ntac

t inf

orm

atio

n fo

r chi

ldre

n in

ve

hicl

es b

eing

use

d fo

r tra

nspo

rt an

d em

erge

ncy

care

pla

ns fo

r chi

ldre

n w

ith c

hron

ic m

edic

al

cond

ition

s.

CH

ILD

REN

’S R

ECO

RD

S

REQ

UIR

EMEN

TS

The

follo

win

g do

cum

enta

tion

is re

quire

d to

be

mai

ntai

ned

in th

e ch

ildre

n’s

cent

er fo

r eac

h ch

ild in

ca

re:

A

sig

ned

stat

emen

t tha

t par

ent o

r leg

al g

uard

ian

rece

ived

a c

opy

of th

is b

roch

ure.

A s

tate

men

t sig

ned

by p

aren

t or l

egal

gua

rdia

n th

at e

nrol

lmen

t inf

orm

atio

n is

com

plet

e an

d ac

cura

te.

A

sig

ned

stat

emen

t tha

t the

chi

ldre

n’s

cent

er h

as

prov

ided

par

ent(s

) or l

egal

gua

rdia

n(s)

a c

opy

of

the

writ

ten

disc

iplin

ary

prac

tices

.

A c

urre

nt h

ealth

exa

min

atio

n re

cord

(not

requ

ired

for s

choo

l age

chi

ldre

n).

A

cur

rent

Flo

rida

Cer

tific

ate

of Im

mun

izat

ion

(not

re

quire

d fo

r sch

ool a

ge c

hild

ren)

.

A n

otar

ized

Em

erge

ncy

Med

ical

Rel

ease

.

Med

ical

reco

rds

that

incl

ude

spec

ial m

edic

al o

r di

etar

y ne

eds

and

a lis

t of a

llerg

ies,

if a

pplic

able

.

Prim

ary

hour

s of

car

e an

d da

ys o

f wee

k in

car

e.

T

elep

hone

num

bers

or i

nstru

ctio

ns a

s to

how

to

reac

h pa

rent

(s) o

r leg

al g

uard

ian(

s) w

hen

child

ren

are

in c

are.

Hos

pita

l pre

fere

nce.

Chi

ld’s

full,

lega

l nam

e, b

irth

date

, dat

e of

en

rollm

ent,

curr

ent a

ddre

ss a

nd p

refe

rred

na

me/

nick

nam

e.

N

ame,

add

ress

, and

tele

phon

e nu

mbe

r of p

aren

t or

lega

l gua

rdia

n.

N

ame,

add

ress

and

tele

phon

e nu

mbe

r of

emer

genc

y pe

rson

(s),

othe

r tha

n pa

rent

or l

egal

gu

ardi

an.

N

ame,

add

ress

and

tele

phon

e nu

mbe

r of

phys

icia

n an

d de

ntis

t.

Pro

of o

f rec

eipt

by

pare

nt(s

) or l

egal

gua

rdia

n(s)

ev

ery

Aug

ust a

nd S

epte

mbe

r of i

nfor

mat

ion

rega

rdin

g ca

uses

, sym

ptom

s, a

nd tr

ansm

issi

on o

f th

e in

fluen

za v

irus.

PER

SON

NEL

REQ

UIR

EMEN

TS

D

irect

or h

as a

Dire

ctor

Cre

dent

ial w

ith th

e ce

rtific

ate

post

ed.

D

ocum

enta

tion

that

sta

ff m

eets

the

staf

f cr

eden

tialin

g re

quire

men

t (no

t req

uire

d fo

r sc

hool

age

cen

ters

).

Com

plet

ion

of b

ackg

roun

d sc

reen

ing.

Com

plet

ion

of 4

0-H

our I

ntro

duct

ory

Chi

ld C

are

train

ing.

Com

plet

ion

of 1

0 ho

urs

train

ing

annu

ally

.

Com

plet

ion

of e

arly

lite

racy

trai

ning

(not

re

quire

d fo

r sch

ool a

ge c

ente

rs).

D

ocum

enta

tion

of e

duca

tiona

l req

uire

men

ts.

M

eet m

inim

um a

ge re

quire

men

ts.

S

igne

d st

atem

ents

that

em

ploy

ees

unde

rsta

nd

the

stat

utor

y re

quire

men

t of r

epor

ting

child

ab

use/

negl

ect.

S

taff

train

ed in

firs

t aid

and

CPR

on

the

prem

ises

at a

ll tim

es a

nd o

n fie

ld tr

ips

S

taff

mai

ntai

n di

rect

sup

ervi

sion

incl

udin

g m

inim

um a

dult-

child

ratio

s:

2

mon

ths-

1 ye

ar

1 ad

ult f

or 3

chi

ldre

n

1

year

-2 y

ears

1

adul

t for

5 c

hild

ren

2 ye

ar o

lds

1 ad

ult f

or 1

0 ch

ildre

n

3 ye

ar o

lds

1 ad

ult f

or 1

5 ch

ildre

n

4 ye

ar o

lds

1 ad

ult f

or 2

0 ch

ildre

n

5 ye

ars

and

up

1 ad

ult f

or 2

5 ch

ildre

n

NU

TRIT

ION

AL R

EQU

IREM

ENTS

Par

ent(s

) or l

egal

gua

rdia

n(s)

not

ified

of

m

eals

pro

vide

d th

at a

re o

f qua

lity

and

quan

tity

to a

ssur

e ch

ild’s

nut

ritio

nal n

eeds

are

met

or

arra

ngem

ents

mad

e fo

r par

ent(s

) or l

egal

gu

ardi

an(s

) to

prov

ide

nutri

tiona

l foo

d.

o

Pos

ted

mea

l and

sna

ck m

enus

. o

S

afe

drin

king

wat

er is

ava

ilabl

e.

PH

YSIC

AL

ENVI

RO

NM

ENT

H

as s

uffic

ient

indo

or s

pace

for p

layi

ng a

nd

napp

ing

that

is k

ept c

lean

, ade

quat

ely

light

ed,

vent

ed a

nd in

goo

d re

pair.

H

as in

door

and

out

door

spa

ce th

at is

cle

an a

nd

free

of li

tter a

nd o

ther

haz

ards

.

Has

toys

, equ

ipm

ent a

nd fu

rnis

hing

s th

at a

re

age

and

deve

lopm

enta

lly a

ppro

pria

te, a

nd a

re

mai

ntai

ned

in a

n op

erab

le, s

afe,

and

san

itary

co

nditi

on.

H

as a

ppro

pria

te b

athr

oom

faci

litie

s th

at a

re

oper

able

, cle

an a

nd s

aniti

zed

(dai

ly).

H

as is

olat

ion

area

for i

ll ch

ildre

n.

H

as e

quip

men

t for

pro

per s

anita

ry h

and

was

hing

, toi

letin

g, a

nd d

iape

ring

activ

ities

.

Has

at l

east

one

cor

ded,

ope

rabl

e te

leph

one

avai

labl

e to

sta

ff.

H

EALT

H R

ELAT

ED E

NVI

RO

NM

ENTA

L R

EQU

IREM

ENTS

Ann

ual a

ppro

ved

fire

insp

ectio

ns c

ondu

cted

.

Mon

thly

che

cks

to e

nsur

e al

l are

as o

f the

ch

ildre

n’s

cent

er a

re fr

ee fr

om fi

re h

azar

ds.

S

mok

ing

is p

rohi

bite

d on

pre

mis

es.

S

tora

ge o

f tox

ic a

nd h

azar

dous

mat

eria

ls in

ar

eas

inac

cess

ible

to c

hild

ren.

Fire

and

em

erge

ncy

drill

s co

nduc

ted

as

requ

ired.

A la

bele

d, fu

lly s

tock

ed fi

rst a

id k

it.

Par

ent(s

) or l

egal

gua

rdia

n(s)

not

ified

of a

ll an

imal

s on

site

.

Rec

ords

of i

mm

uniz

atio

ns fo

r ani

mal

s/fo

wl.

P

rohi

bit f

ire a

rms

or w

eapo

ns o

n pr

emis

es

(exc

ludi

ng fe

dera

l, st

ate

and

loca

l law

en

forc

emen

t offi

cers

).

P

rohi

bit n

arco

tics,

alc

ohol

or o

ther

impa

iring

dr

ugs

on th

e pr

emis

es.

B

imon

thly

out

door

equ

ipm

ent m

aint

enan

ce

chec

ks.


Last modified 07/04/2019Duri

ng t

he

2009 leg

isla

tive

ses

sion, a

new

law

was

pas

sed t

hat

req

uir

es c

hild

ca

re f

acilit

ies,

fam

ily

day

car

e hom

es

and lar

ge

fam

ily

child c

are

hom

es

pro

vide

par

ents

wit

h info

rmat

ion

det

ailing t

he

cause

s, s

ympto

ms,

and

tr

ansm

issi

on o

f th

e in

fluen

za v

irus

(the

flu) ev

ery

year

duri

ng A

ugust

and

S

epte

mber

.M

y s

ign

atu

re b

elo

w v

eri

fies

receip

t o

f th

e

bro

ch

ure

on

In

flu

en

za V

iru

s, T

he F

lu,

A

Gu

ide t

o P

are

nts

:

Nam

e: _

____

____

____

____

____

____

____

___

Ch

ild

’s N

am

e: _

____

____

____

____

____

___

Date

Receiv

ed

: ___

____

____

____

____

____

Sig

natu

re: _

____

____

____

____

____

____

___

Ple

ase

com

ple

te a

nd r

eturn

this

port

ion o

f th

e bro

chure

to y

our

child c

are

pro

vider

, in

ord

er f

or

them

to m

ainta

in it

in t

hei

r re

cord

s.

What

should

I d

o if

my

child

get

s si

ck?

Con

sult

your

doc

tor

and

mak

e su

re y

our

child

get

s pl

enty

of r

est a

nd d

rink

s a

lot o

f flui

ds. N

ever

giv

e as

piri

n or

med

icin

e th

at h

as a

spir

in in

it to

chi

ldre

n or

teen

ager

s w

ho m

ay h

ave

the

flu.

CA

ll o

R T

Ak

e y

ou

R C

hIl

D T

o A

D

oC

To

R R

IGh

T A

WA

y IF

yo

uR

Ch

IlD

:•

Has

a h

igh

feve

r or

feve

r th

at la

sts

a lo

ng ti

me

• H

as tr

oubl

e br

eath

ing

or b

reat

hes

fast

• H

as s

kin

that

look

s bl

ue•

Is n

ot d

rink

ing

enou

gh•

See

ms

conf

used

, will

not

wak

e up

, doe

s no

t w

ant t

o be

hel

d, o

r ha

s se

izur

es (u

ncon

trol

led

shak

ing)

• G

ets

bett

er b

ut th

en w

orse

aga

in•

Has

oth

er c

ondi

tions

(lik

e he

art o

r lu

ng

dise

ase,

dia

bete

s) th

at g

et w

orse

What

can

I d

o t

o p

reve

nt

the

spre

ad o

f ger

ms?

The

mai

n w

ay th

at th

e flu

spr

eads

is in

res

pira

tory

dr

ople

ts fr

om c

ough

ing

and

snee

zing

. Th

is c

an

happ

en w

hen

drop

lets

from

a c

ough

or

snee

ze o

f an

infe

cted

per

son

are

prop

elle

d th

roug

h th

e ai

r an

d in

fect

som

eone

nea

rby.

Tho

ugh

muc

h le

ss fr

eque

nt,

the

flu m

ay a

lso

spre

ad th

roug

h in

dire

ct c

onta

ct w

ith

cont

amin

ated

han

ds a

nd a

rtic

les

soile

d w

ith n

ose

and

thro

at s

ecre

tions

. To

pre

vent

the

spre

ad o

f ger

ms:

• W

ash

hand

s of

ten

with

soa

p an

d w

ater

.•

Cov

er m

outh

/nos

e du

ring

co

ughs

and

sne

ezes

. If

you

don’

t hav

e a

tissu

e,

coug

h or

sne

eze

into

you

r up

per

slee

ve, n

ot y

our

hand

s.•

Lim

it co

ntac

t with

peo

ple

who

sho

w s

igns

of i

llnes

s.•

Kee

p ha

nds

away

from

the

face

. G

erm

s ar

e of

ten

spre

ad w

hen

a pe

rson

to

uche

s so

met

hing

that

is

cont

amin

ated

with

ger

ms

and

then

touc

hes

his

or

her

eyes

, nos

e, o

r m

outh

.

When

should

my

child

st

ay h

om

e fr

om

child c

are?

A p

erso

n m

ay b

e co

ntag

ious

and

abl

e to

spr

ead

the

viru

s fr

om 1

day

bef

ore

show

ing

sym

ptom

s to

up

to 5

day

s af

ter

gett

ing

sick

. Th

e tim

e fr

ame

coul

d be

long

er in

chi

ldre

n an

d in

peo

ple

who

don

’t fig

ht d

isea

se w

ell (

peop

le w

ith w

eake

ned

imm

une

syst

ems)

. W

hen

sick

, you

r ch

ild s

houl

d st

ay a

t hom

e to

res

t and

to a

void

giv

ing

the

flu to

oth

er c

hild

ren

and

shou

ld n

ot r

etur

n to

chi

ld c

are

or o

ther

gro

up s

ettin

g un

til h

is o

r he

r te

mpe

ratu

re h

as b

een

norm

al a

nd h

as

been

sig

n an

d sy

mpt

om fr

ee fo

r a

peri

od o

f 24

hour

s.

For

addit

ional

hel

pfu

l in

form

atio

n a

bout

the

dan

ger

s of

the

flu a

nd

how

to p

rote

ct y

our

child, vi

sit:

htt

p://w

ww

.cdc

.gov

/flu/

how

can

I p

rote

ct m

y ch

ild

fr

om

the

flu?

A

flu

vacc

ine

is th

e be

st w

ay to

pro

tect

aga

inst

th

e flu

. B

ecau

se th

e flu

vir

us c

hang

es y

ear

to y

ear,

annu

al v

acci

natio

n ag

ains

t the

flu

is

reco

mm

ende

d. T

he C

DC

rec

omm

ends

that

all

child

ren

from

the

ages

of 6

mon

ths

up to

thei

r 19

th b

irth

day

rece

ive

a flu

vac

cine

eve

ry fa

ll or

w

inte

r (c

hild

ren

rece

ivin

g a

vacc

ine

for

the

first

tim

e re

quir

e tw

o do

ses)

. Yo

u al

so c

an p

rote

ct

your

chi

ld b

y re

ceiv

ing

a flu

vac

cine

you

rsel

f.


Last modified 07/04/2019INFlueNzA VIRuS INFlueNzA VIRuS

“The

Flu”

A

Guid

e

for

Par

ents

For

addi

tiona

l inf

orm

atio

n, p

leas

e vi

sit

ww

w.m

yflor

ida.

com

/chi

ldca

re o

r co

ntac

t you

r lo

cal l

icen

sing

offi

ce b

elow

:

This

bro

chur

e w

as c

reat

ed b

y th

e D

epar

tmen

t of C

hild

ren

and

Fam

ilies

in c

onsu

ltatio

n w

ith th

e D

epar

tmen

t of H

ealth

.

CF/

PI 1

75-7

0, J

une

2009

What

is

the

infl

uen

za (fl

u) vi

rus?

Influ

enza

(“th

e flu

”) is

cau

sed

by a

vir

us w

hich

in

fect

s th

e no

se, t

hroa

t, an

d lu

ngs.

Acc

ordi

ng to

th

e U

S C

ente

r fo

r D

isea

se C

ontr

ol a

nd P

reve

ntio

n (C

DC

), th

e flu

is m

ore

dang

erou

s th

an th

e co

mm

on

cold

for

child

ren.

Unl

ike

the

com

mon

col

d, th

e flu

can

cau

se s

ever

e ill

ness

and

life

thre

aten

ing

com

plic

atio

ns in

man

y pe

ople

. C

hild

ren

unde

r 5

who

ha

ve th

e flu

com

mon

ly n

eed

med

ical

car

e. S

ever

e flu

co

mpl

icat

ions

are

mos

t com

mon

in c

hild

ren

youn

ger

than

2 y

ears

old

. Fl

u se

ason

can

beg

in a

s ea

rly

as

Oct

ober

and

last

as

late

as

May

.

how

can

I t

ell if

my

child h

as a

cold

, or

the

flu?

M

ost p

eopl

e w

ith th

e flu

feel

tire

d an

d ha

ve fe

ver,

head

ache

, dry

cou

gh, s

ore

thro

at, r

unny

or

stuf

fy

nose

, and

sor

e m

uscl

es.

Som

e pe

ople

, esp

ecia

lly

child

ren,

may

als

o ha

ve s

tom

ach

prob

lem

s an

d di

arrh

ea.

Bec

ause

the

flu a

nd c

olds

hav

e si

mila

r sy

mpt

oms,

it c

an b

e di

fficu

lt to

tell

the

diff

eren

ce

betw

een

them

bas

ed o

n sy

mpt

oms

alon

e. In

ge

nera

l, th

e flu

is w

orse

than

the

com

mon

col

d,

and

sym

ptom

s su

ch a

s fe

ver,

body

ach

es, e

xtre

me

tired

ness

, and

dry

cou

gh a

re m

ore

com

mon

and

in

tens

e. P

eopl

e w

ith c

olds

are

mor

e lik

ely

to h

ave

a ru

nny

or s

tuff

y no

se. C

olds

gen

eral

ly d

o no

t res

ult

in s

erio

us h

ealth

pro

blem

s, s

uch

as p

neum

onia

, ba

cter

ial i

nfec

tions

, or

hosp

italiz

atio

ns.



Rev

ised

6/2

017

Pa

ge 1

of 2

I-009-12

CH

ILD

CA

RE

FOO

D P

RO

GR

AM

FR

EE A

ND

RED

UC

ED-P

RIC

E M

EAL

APP

LIC

ATI

ON

Chi

ld’s

Nam

e: _

____

____

____

____

____

____

____

____

_ C

ente

r Nam

e &

Add

ress

: ___

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

Plea

se re

ad th

e in

stru

ctio

ns a

nd a

ccom

pany

ing

Pare

nt L

ette

r bef

ore

com

plet

ing

this

form

. If y

ou n

eed

assi

stan

ce c

ompl

etin

g th

is fo

rm, c

all:

(___

___)

___

____

____

____

____

____

STEP

1: C

ompl

ete

the

follo

win

g ta

ble

for a

ll IN

FAN

TS a

nd C

HIL

DR

EN th

roug

h ag

e 18

that

resi

de in

the

hous

ehol

d, e

ven

if no

t rel

ated

. (in

clud

e ch

ild li

sted

at t

op o

f for

m)…

……

.…

Chi

ld’s

Nam

e (L

ast N

ame,

Firs

t Nam

e)

Dat

e of

Birt

hAt

tend

s th

is c

ente

r? (c

ircle

)Fo

ster

Chi

ld?

(circ

le)

Mig

rant

? (c

ircle

)H

omel

ess/

Run

away

? (c

ircle

)

Ye

s

No

Yes

N

o Ye

s

No

Yes

N

o

Ye

s

No

Yes

N

o Ye

s

No

Yes

N

o

Ye

s

No

Yes

N

o Ye

s

No

Yes

N

o ST

EP 2

: Do

any

hous

ehol

d m

embe

rs (c

hild

ren

or a

dults

) rec

eive

Foo

d As

sist

ance

Pro

gram

(FAP

/SN

AP) o

r Tem

pora

ry A

ssis

tanc

e fo

r Nee

dy F

amili

es (T

ANF)

ben

efits

?....

......

...

If N

O, g

o to

STE

P 3.

If Y

ES, e

nter

one

of t

he fo

llow

ing

case

num

bers

, the

n go

to S

TEP

4.

FAP/

SNAP

Cas

e N

umbe

r: __

_ __

_ __

_ __

_ __

_ __

_ __

_ __

_ __

_ __

_ or

TAN

F C

ase

Num

ber:

___

___

___

___

___

___

___

___

___

___

STEP

3: H

ouse

hold

inco

me

and

adul

t hou

seho

ld m

embe

r inf

orm

atio

n (s

ee re

vers

e si

de fo

r wha

t typ

es o

f inc

ome

to re

port

) (sk

ip th

is s

tep

if yo

u lis

ted

a ca

se #

in S

TEP

2)…

......

...n

A.

Chi

ldre

n’s

Inco

me

– so

met

imes

chi

ldre

n ea

rn o

r rec

eive

inco

me.

Ent

er th

e to

tal i

ncom

e re

ceiv

ed b

y al

l chi

ldre

n lis

ted

in S

TEP

1, th

en c

heck

how

ofte

n th

e in

com

e is

rece

ived

.

Tota

l chi

ldre

n’s

inco

me:

$

How

ofte

n re

ceiv

ed?

(che

ck o

nly

one)

: □

Wee

kly

□ B

i-Wee

kly

□ T

wic

e a

Mon

th □

Mon

thly

□

Annu

ally

B.

Adul

t Hou

seho

ld M

embe

rs a

nd In

com

e –

list a

ll ad

ult h

ouse

hold

mem

bers

(age

19

and

up) e

ven

if th

ey d

o no

t rec

eive

inco

me.

For

eac

h ad

ult,

list t

he to

tal g

ross

inco

me

(bef

ore

taxe

s &

ded

uctio

ns) f

rom

eac

h so

urce

in w

hole

dol

lars

onl

y (n

o ce

nts)

and

how

ofte

n it

is re

ceiv

ed (i

.e.,

wee

kly,

bi-w

eekl

y, tw

ice

a m

onth

, mon

thly

, or a

nnua

lly).

For a

n ad

ult t

hat d

oes

not r

ecei

ve in

com

e fro

m a

ny s

ourc

e, w

rite

“non

e” o

r “0.

” If

you

ente

r “no

ne” o

r “0”

or l

eave

any

inco

me

field

s bl

ank,

you

are

cer

tifyi

ng th

at th

ere

is n

o in

com

e to

repo

rt.

Adul

t Hou

seho

ld M

embe

r’s N

ame

(Las

t Nam

e, F

irst N

ame)

Ea

rnin

gs fr

om W

ork

($ A

mou

nt /

How

ofte

n?)

Publ

ic A

ssis

tanc

e/C

hild

Sup

port

/Alim

ony

($ A

mou

nt /

How

ofte

n?)

Pens

ions

/Ret

irem

ent/A

ll O

ther

Inco

me

($ A

mou

nt /

How

ofte

n?)

$

/ Wee

kly Biwee

kly Mon

thly

Twice a Mon

th A

nnua

lly$

/ Wee

kly Biwee

kly Mon

thly

Twice a Mon

th A

nnua

lly$

/ Wee

kly Biwee

kly Mon

thly

Twice a Mon

th A

nnua

lly

$

/ Wee

kly Biwee

kly Mon

thly

Twice a Mon

th A

nnua

lly$

/ Wee

kly Biwee

kly Mon

thly

Twice a Mon

th A

nnua

lly$

/ Wee

kly Biwee

kly Mon

thly

Twice a Mon

th A

nnua

lly

$

/ Wee

kly Biwee

kly Mon

thly

Twice a Mon

th A

nnua

lly$

/ Wee

kly Biwee

kly Mon

thly

Twice a Mon

th A

nnua

lly$

/ Wee

kly Biwee

kly Mon

thly

Twice a Mon

th A

nnua

lly

Tota

l Hou

seho

ld M

embe

rs (c

hild

ren

and

adul

ts):

____

__ L

ast f

our d

igits

of S

ocia

l Sec

urity

Num

ber (

SSN

) of a

dult

hous

ehol

d m

embe

r:|__

_||__

_||__

_||__

_| If

no S

SN, w

rite

“non

e.”

STEP

4: C

onta

ct in

form

atio

n an

d ad

ult s

igna

ture

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

.……

……

...…

By

sig

ning

bel

ow, I

am

cer

tifyi

ng (p

rom

isin

g) th

at a

ll in

form

atio

n on

this

app

licat

ion

is tr

ue a

nd th

at a

ll in

com

e is

repo

rted.

I un

ders

tand

that

this

info

rmat

ion

is b

eing

giv

en in

con

nect

ion

with

the

rece

ipt

of fe

dera

l fun

ds a

nd th

at in

stitu

tion

offic

ials

may

ver

ify (c

heck

) the

info

rmat

ion.

I am

aw

are

that

if I

purp

osel

y gi

ve fa

lse

info

rmat

ion,

I m

ay b

e pr

osec

uted

und

er a

pplic

able

sta

te a

nd fe

dera

l law

s.

Hom

e ad

dres

s (if

ava

ilabl

e): _

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

Day

time

phon

e #:

(___

____

) ___

____

_ –

____

____

__

St

reet

Add

ress

, City

, Sta

te, Z

ip C

ode

Sign

atur

e of

adu

lt ho

useh

old

mem

ber:

___

____

____

____

____

____

____

____

____

____

Prin

ted

nam

e: _

____

____

____

____

____

____

____

____

___

Dat

e si

gned

: ___

____

____

____

_

OPT

ION

AL: C

hild

’s e

thni

c an

d ra

cial

iden

titie

s

We

are

requ

ired

to a

sk fo

r inf

orm

atio

n ab

out y

our c

hild

’s e

thni

city

and

race

. Thi

s in

form

atio

n is

impo

rtant

and

hel

ps m

ake

sure

that

we

are

fully

ser

ving

the

com

mun

ity.

Res

pond

ing

to th

is s

ectio

n is

opt

iona

l and

doe

s no

t affe

ct y

our c

hild

’s e

ligib

ility

for f

ree

or re

duce

d-pr

ice

mea

ls.

Eth

nici

ty (c

heck

one

): _

__ H

ispa

nic

or L

atin

o

___

Not

His

pani

c or

Lat

ino

Rac

e (c

heck

one

or m

ore)

: _

__ A

mer

ican

Indi

an o

r Ala

skan

Nat

ive

___

Asia

n

__

_ Bl

ack

or A

frica

n Am

eric

an

_

__ N

ativ

e H

awai

ian

or O

ther

Pac

ific

Isla

nder

___

Whi

te

FOR

CO

NTR

ACTO

R U

SE O

NLY

:……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

……

...…

….…

……

.XX

Cat

egor

ical

Elig

ibili

ty: □

FAP

/SN

AP o

r TAN

F H

ouse

hold

□

Fos

ter C

hild

Tot

al H

ouse

hold

Siz

e: _

____

__

Tot

al H

ouse

hold

Inco

me:

$__

____

____

____

Elig

ibili

ty D

eter

min

atio

n: □

Fre

e

□ R

educ

ed-P

rice

□

Non

-nee

dy

H

ow O

ften

Inco

me

is R

ecei

ved

(Fre

quen

cy): □

Wee

kly

□

Biw

eekl

y

□ T

wic

e a

Mon

th

□ M

onth

ly

□ A

nnua

lly

NO

TE: I

f diff

eren

t inc

ome

freq

uenc

ies

are

liste

d, c

onve

rt a

ll in

com

e to

an

annu

al a

mou

nt.

Annu

al In

com

e C

onve

rsio

n: W

eekl

y x

52, B

iwee

kly

x 26

, Tw

ice

a M

onth

x 2

4, M

onth

ly x

12

Rea

son

for N

on-n

eedy

Sta

tus:

□ In

com

e to

o H

igh

□

Inco

mpl

ete

Appl

icat

ion

□

Oth

er R

easo

n: _

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

_

Det

erm

inin

g O

ffici

al’s

Sig

natu

re: _

____

____

____

____

____

____

____

____

____

_ D

ate:

___

____

____

____

S

econ

d Pa

rty

Che

ck S

igna

ture

: ___

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Documents

Please be sure to complete the following checklist. · Other relative / kinship care: Dual parent, married Other relative / kinship care: Single parent, female head of house Other