Toddler Enrollment Packet

MISSOURI DEPARTMENTOF HEALTH AND SENIOR SERVICES (MDHSS) COMMUNITY FOOD AND NUTRITION ASSISTANCE – CHILD AND ADULT CARE FOOD PROGRAM (CACFP)

CACFP ENROLLMENT FORM FOR CHILD CARE CENTERS NOTE: DEPARTMENT OF HEALTH AND SENIOR SERVICES OFFICIALS OR A SPONSORING ORGANIZATION REPRESENTATIVE MAY CONTACT YOU TO VERIFY INFORMATION. CHILD’S FULL NAME

DATE OF BIRTH

PARENT OR GUARDIAN NAME

STREET ADDRESS

CITY

STATE

ZIP CODE

DAYTIME PHONE NUMBER

( NAME OF CHILD CARE CENTER

)

PHONE NUMBER

( CENTER CONTACT PERSON’S NAME

)

CHILD’S DATE OF ENROLLMENT (FIRST DATE ATTENDING THIS CENTER)

IN THIS COLUMN, WHAT TIME DOES YOUR CHECK THE DAYS YOUR CHILD USUALLY ARRIVE CHILD USUALLY EACH DAY? CIRCLE AM OR PM ATTENDS DAY CARE !"

WHAT TIME DOES YOUR CHILD USUALLY LEAVE EACH DAY?

WRITE ANY COMMENTS, CHANGES OR VARIATIONS IN USUAL ATTENDANCE IN THIS SECTION.

CIRCLE AM OR PM

MON

AM

PM

AM

PM

TUES

AM

PM

AM

PM

WED

AM

PM

AM

PM

THURS

AM

PM

AM

PM

FRI

AM

PM

AM

PM

SAT

AM

PM

AM

PM

SUN

AM

PM

AM

PM

CHECK WHEN YOUR CHILD IS IN CARE AT THIS CENTER ❏ FULL DAY CARE ❏ BEFORE SCHOOL CARE ❏ EVENING CARE ❏ HALF DAY – MORNING ❏ AFTER SCHOOL CARE ❏ OVERNIGHT CARE ❏ HALF DAY – AFTERNOON ❏ BEFORE AND AFTER SCHOOL CARE CHECK THE MEALS YOUR CHILD IS USUALLY GIVEN AT THIS CENTER ❏ BREAKFAST ❏ LUNCH ❏ SUPPER ❏ MORNING SNACK ❏ AFTERNOON SNACK ❏ EVENING SNACK CHECK THE HOLIDAYS YOUR CHILD IS IN CARE AT THIS CENTER ❏ NEW YEARS DAY (JANUARY 1) ❏ INDEPENDENCE DAY (JULY 4) ❏ MARTIN LUTHER KING’S BIRTHDAY (JANUARY) ❏ LABOR DAY (SEPTEMBER) ❏ PRESIDENT’S DAY (FEBRUARY) ❏ THANKSGIVING DAY (NOVEMBER) ❏ MEMORIAL DAY (MAY) ❏ CHRISTMAS DAY (DECEMBER 25) SIGNATURE OF PARENT OR GUARDIAN

DATE

ANNUAL UPDATES: THE PARENT OR GUARDIAN SIGNING THIS FORM CERTIFIES THAT THE ENROLLMENT INFORMATION IS CORRECT. IF INFORMATION HAS CHANGED, THE PARENT OR GUARDIAN HAS WRITTEN THE APPROPRIATE CHANGES ON THE FORM AND INITIALED THE CHANGE. IF THERE ARE MANY CHANGES, PLEASE COMPLETE A NEW FORM. FIRST ANNUAL UPDATE

PARENT SIGNATURE

DATE

SECOND ANNUAL UPDATE

PARENT SIGNATURE

DATE

THIRD ANNUAL UPDATE

PARENT SIGNATURE

DATE

MO 580-2756 (3-05)

CACFP- 229

MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES BUREAU OF COMMUNITY FOOD AND NUTRITION ASSISTANCE CHILD AND ADULT CARE FOOD PROGRAM

INCOME ELIGIBILITY FORM FOR CHILD CARE CENTERS To apply for free or reduced-price meal eligibility benefits for your child(ren), please fill out this form and return it to the child care center. PART 1 CHILDREN ENROLLED AT THE CHILD CARE CENTER Complete information below for children enrolled at the center. If child(ren) are receiving Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamp) or Temporary Assistance (formerly AFDC, now funded by TANF), complete Parts 1, 3, and 4 only. Complete Parts 1, 2, 3, and 4 if you did not provide a SNAP case number or Temporary Assistance case number for all of the children listed in Part 1. FOSTER SNAP TEMPORARY ASSISTANCE NAME (first and last) BIRTH DATE CHILD CASE NUMBER CASE NUMBER

PART 2 HOUSEHOLD AND INCOME INFORMATION List all members of the household including the children listed in Part 1. Indicate source and amount of current monthly gross income for all members of the household before deductions, such as taxes and social security. Where there are wage earners and self-employed adults, the income of the wage earner cannot be offset by the business losses of the self-!"#$%&!'( )'*$+,( ( -.( $)/+( "%0+12/( 304%"!( '%!/( 0%+( accurately reflect your circumstances, you may provide a projection of your current annual income. Irregular self-employed income may be averaged over the prior 12 months. Foster children may be eligible regardless of household income. Contact the center for more information. YEARLY

INCOME BASED ON (CHECK ONE)

MONTHLY

!"

HOUSEHOLD MEMBERS

2 X A MONTH

"

"

EVERY 2 WEEKS

"

PENSIONS, RETIREMENT, SOCIAL SECURITY

WELFARE, CHILD SUPPORT, ALIMONY

GROSS WAGES

WEEKLY

"

OTHER

PART 3 RACIAL ETHNIC INFORMATION (You are not required to answer this section) Are you of Hispanic or Latino origin? YES NO What is your race? (Select one or more)

AMERICAN INDIAN OR ALASKA NATIVE

ASIAN

BLACK OR AFRICAN AMERICAN

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

WHITE

"

"

"

"

"

PART 4 SIGNATURE I hereby certify that all information provided is correct. I understand that this information is being given in connection with the receipt of federal funds, that institution officials may verify information, and that deliberate misrepresentation may subject me to prosecution under applicable state and federal laws. SIGNATURE OF ADULT FAMILY MEMBER

SOCIAL SECURITY NUMBER

DATE

ADDRESS

PHONE NUMBER

! PRINTED NAME OF ADULT

Section 9 of the National School Lunch Act requires +1)+5(*0$!//(&%*6( 413$'6!02/(SNAP or Temporary Assistance case number is provided, you must include a social security number of the adult household member signing the application or indicate that the household member signing the application does not possess a social security number. Provision of a social security number is not mandatory, but if a social security number is not provided or an indication is not made that the signer has none, the application cannot be approved. The social security number may be used to identify the household member in carrying out efforts to verify the accuracy of information stated on the application. These verification efforts may be carried out through program reviews and investigations, and may include contacting employers to determine income, contacting a SNAP or welfare office to determine current certification for receipt of SNAP or Temporary Assistance benefits, contacting the State employment security office to determine the amount of benefits received and checking the documentation produced by the household member to provide the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims, or legal actions if incorrect information is reported. TOTAL HOUSEHOLD SIZE:

!"#$%&'(&#$)*&$"'+,$$$$

INCOME:

INCOME BASED ON (CHECK ONE): YEAR

"

Eligibility Determination:

" Free

SIGNATURE OF CENTER REPRESENTATIVE

!!!!!!!!!

MO 580-1314 (5-09)

MONTH

" Reduced

"

2 X A MONTH

"

EVERY 2 WEEKS

"

WEEKLY

"

SNAP (Food Stamp)

"

TEMPORARY ASSISTANCE

"

" Paid DATE CACFP-205

MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES SECTION FOR CHILD CARE REGULATION

CHILD MEDICAL EXAMINATION REPORT (INFANT/TODDLER/PRE-SCHOOL) IDENTIFYING INFORMATION CHILD’S NAME

BIRTHDATE

CURRENT STATE OF HEALTH Based on my assessment of this child’s medical history, current state of health and my physical examination of the child on ____ / ____ / ____, this child can participate in a child care program. This child has no special care needs unless specified below.

(Date of medical examination must be within the last 12 months.) PHYSICIAN’S INSTRUCTIONS FOR SPECIALIZED CARE Complete this section only if child requires special care at a child care facility, e.g. special diets, allergies, ear infections, convulsions, diabetes, asthma, behavior problems, hearing or visual impairment, etc. (Attach additional pages as needed.)

SIGNATURE OF PHYSICIAN OR REGISTERED NURSE UNDER THE SUPERVISION OF A PHYSICIAN

DATE

PHYSICIAN’S OR NURSE’S NAME (PLEASE PRINT)

NAME AND ADDRESS OF CLINIC, GROUP, PRACTICE OR OTHER (MAY USE STAMP.)

IF NURSE IS SUPERVISED BY A PHYSICIAN, INDICATE PHYSICIAN’S NAME (PLEASE PRINT.) TELEPHONE NUMBER

MO 580-1878 (9-07)

TO BE FILED IN CHILD’S RECORD AT CHILD CARE FACILITY

BCC-6A

SAFE N SOUND PLAYGROUND POLICIES AND PROCEDURES o Your payment of _____________ is due by Friday for the following week. Payments may be put in the black payment box hanging on the wall by the offices. For every day past Friday that payment is not made, a $5.00 late fee per day will be applied to the account. If tuition is not paid for 2 weeks, your child will not be allowed to return until the balance is paid in full. o The center will be closed on all major holidays, however payment is still due for your child’s scheduled days. o A child should not be in attendance and will be sent home for the following: • Fever above 100 degrees (99 degrees under the arm) • Vomiting or diarrhea that occurs more than 2 times • Head Lice • Other symptoms related to a communicable disease (rash, swollen glands, etc) If your child is sent home for any of these reasons, they must be symptom free without medication for at least 24 hours before they can return. o Each family is allowed vacation time equal to one week of your child’s enrolled days. For example, if your child comes 5 days a week they receive 5 vacation days. If they come 3 days a week, they receive 3 days. Vacation time is available after your child has attended the center for 30 days. Vacation time renews every January. In order to use the vacation days, your child must be absent from the center and you must notify the directory that you want to use the days. o Please call and let us know if your child will not be coming on a scheduled day. Also, if your child will be arriving after 10:00 am, please call so that we can include them in our lunch count. o Please bring the following items for your child: • Extra change of clothes • Sheet, blanket, and special toy for naptime • Baby food, formula, and bottles for infants • Diapers and wipes if needed • Shot records must be turned in before the child can start Parent signature __________________________________________________________ Director signature _________________________________________________________

SAFE N SOUND PLAYGROUND TODDLER INFORMATION Child’s name: ____________________________________________________ Nickname: ____________ DOB: ___/___/___ Are any medications given regularly?

Age: _____

( ) Yes

Sex: ____

( ) No

What is your child’s favorite food? ___________________________________ What food does your child dislike? ___________________________________ Does your child drink from: Does your child eat with:

Cup w/ lid spoon

fork

Does he/she sleep through the night?

hands ( ) Yes

Does your child take an afternoon nap? Special toy or blanket for naptime?

Cup Bottle Breast fed

( ) No

( ) Yes

( ) Yes

( ) No How long? ________

( ) No What? _____________

What form of discipline is most often used in the child’s home? ____________ ______________________________________________________________ How does your child behave when sick? _______________________________ How is your child most easily settled when upset or afraid? ________________ What are your child’s favorite activities, toys, books, or games? ____________ _____________________________________________________________ What are the names and ages of your child's siblings: Name ___________________________________ Age: _________________ Name ___________________________________ Age: __________________ Name ___________________________________ Age: __________________ Additional comments or instructions: _________________________________ ______________________________________________________________ ______________________________________________________________

Safe N Sound Playground I, _________________________________, give permission for Safe N Sound Playground and any employees of to lay my child, who is at least 12 months of age, on a cot to sleep.

Signature of Parent

Date