Parent Name *

First Name

Last Name

ChildName *

First Name

Last Name

Child DOB *

MM

DD

YYYY

Checkbox *

I grant permission for my child to use all of the play equipment and participate in all of the activities of the school

I grant permission for my child to leave the school premises under the supervision of a staff member for neighborhood walks, i.e., Edgewood Park vicinity,

I grant permission for Teaching Staff and other regulatory staff to have access to Medical &/or Assessment information as needed to better serve my child or improve the effectiveness of the childcare center. Any other access to these records will require a separate written consent from me.,

I grant permission to take whatever emergency, (e.g., first aid, disaster evacuation) measures as judged necessary for the care and protection of my child while under the supervision of the school as warranted. Teachers treat minor accidents, such as scrapes or bumps we will apply first aid using universal precaution,

It is understood that in some medical situations, the staff will need to contact the local emergency resource before the parent, child's physician, and/or other adult acting on the parent's behalf. In case of a medical emergency,

I understand that my child will be transported to an appropriate medical facility by the local emergency unit for treatment if the local emergency resource (Police, Rescue Squad) deem it necessary.,

I grant permission for my child to be included in evaluations and photographs/videos connected with the school’s programs,

I have received a copy of the calendar and know when the center will be closed,

I grant permission for Morning Glory to share phone numbers and emails with other families for the purpose of connecting for social events including parties and playdates etc. (Morning Glory does not distribute invitations at school.)

Parent *

First Name

Last Name

Child *

First Name

Last Name

These are the activities I would like to be involved in *

Class Projects

Advisory Board

Read to Children

Field Trips

Hobbies/Talent

Lending Library

None

When are the best days and times?

Monday

Tuesday

Wednesday

Thursday

Friday

Early Morning

Late Morning

Early Afternoon

Late Afternoon

Parent *

First Name

Last Name

Mission Statement *

OK

Philosophy *

OK

Staff/Greeter *

OK

Arrival/Departure Times *

OK

Closings/Calendar *

OK

Snow Day Policy *

OK

Clothes/Toys *

OK

Food/Allergies/Meal Schedule *

OK

Celebrations *

OK

Transition *

OK

Parent Involvement *

OK

Curriculum *

OK

Parent Conference *

OK

Field Trip *

OK

Lending Library *

OK

Parent Concerns *

OK

Health and Medication *

OK

Toileting *

OK

Discipline *

OK

Child Abuse *

OK

Tuition Policy *

OK

Pick-up Policy *

OK

Termination Policy *

OK

Grievance Procedure *

OK

Parking Procedure *

OK

Preschool Expectations *

OK

Family Strengths and Goals *

OK

Parent Name *

First Name

Last Name

Child Name *

First Name

Last Name

Child DOB *

MM

DD

YYYY

My family would like more information on the following: *

Health/Medical Services

Counseling/Outreach Services

Financial Services

Mental Health Services

Emergency Crisis

GED/Adult Education

Legal Services

Resource Lending Library

Employment & Training Centers

Social Services

Family Disability Services

Child Disability Services

I don't need anything at this time.

Parent Name *

First Name

Last Name

Child Name *

First Name

Last Name

Child DOB *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Child's Name *

First Name

Last Name

Child's DOB *

MM

DD

YYYY

Expected Date of Enrollment *

MM

DD

YYYY

Day(s) *

Monday

Tuesday

Wednesday

Thursday

Friday

Start Hours *

Hour

Minute

Second

AM PM

End Hours *

Hour

Minute

Second

AM PM

Medical Care Provider Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical Care Provider Phone

(###)

###

####

Last Physical Exam

MM

DD

YYYY

Child's Physician

First Name

Last Name

Physician Address

If different than medical provider.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physician Phone

(###)

###

####

Last Dental Exam

MM

DD

YYYY

Child's Dentist *

First Name

Last Name

Dental Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dental Phone

(###)

###

####

Permissions *

Check off all permissions granted

I grant permission for Teaching Staff and other regulatory staff to have access to Medical &/or Assessment information as needed to better serve my child or improve the effectiveness of the childcare center. Any other access to these records will require a separate written consent from me.

I grant permission to take whatever emergency, (e.g., first aid, disaster evacuation) measures as judged necessary for the care and protection of my child while under the supervision of the school as warranted. Teachers treat minor accidents, such as scrapes or bumps we will apply first aid using universal precaution

It is understood that in some medical situations, the staff will need to contact the local emergency resource before the parent, child's physician, and/or other adult acting on the parent's behalf. In case of a medical emergency, I understand that my child will be transported to an appropriate medical facility by the local emergency unit for treatment if the local emergency resource (Police, Rescue Squad) deem it necessary.

I grant permission for my child to use all of the play equipment and participate in all of the activities of the school

I grant permission for my child to leave the school premises under the supervision of a staff member for neighborhood walks, i.e., Edgewood Park vicinity

I grant permission for my child to be included in evaluations and photographs/videos connected with the school’s programs

I have received a copy of the calendar and know when the center will be closed

I grant permission for Morning Glory to share phone numbers and emails with other families for the purpose of connecting for social events including parties and play dates etc. (Morning Glory does not distribute invitations at school.)

SCG

First Name

Last Name

SCG Contact #

(###)

###

####

Parent Name *

First Name

Last Name

Child Name *

First Name

Last Name

Emergency Contact 1 *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Pick Up? *

This person is also on my Pick Up List

This person is NOT on my pick Up List

Emergency Contact 2 *

First Name

Last Name

Emergency Contact Phone 2 *

(###)

###

####

Pick Up? *

This person is also on my Pick Up List

This person is NOT on my Pick Up List

Name *

First Name

Last Name

Phone *

(###)

###

####

Name 2

First Name

Last Name

Phone 2

(###)

###

####

Name 3

First Name

Last Name

Phone 3

(###)

###

####

Name 4

First Name

Last Name

Phone 4

(###)

###

####

Primary Care Giver PCG *

First Name

Last Name

Please check off any of the following that has happened with your baby. *

Eye problems

Jaundice

Fevers

Infections

Heart Problems

Skin Conditions

Jittery/Shaky

Problems Breathing

Trouble Feeding

Hospitalizations

Other

None

If your baby is 2 months or older, check off if they have done the following. *

If not yet, do not check off.

Smile or respond to smiles

Roll over

Sit alone

Crawl

Take 10 steps alone

Babble

Join words

Make eye contact

Is your child allergic to any of the following? *

Animals

Perfume

Birds

Pollen

Grass

Flowers

Dust

Trees

Smoke

Weather Changes

Other

Nothing

Has your child ever had the following illnesses? *

Measles

Ear/Nose/Throat Problems

Eye Problems

Mumps

Urinary/Kidney Problems

Heart Disease

Chickenpox

Muscle/Bone Problems

Pneumonia

Scarlet Fever

Anemia

Intestinal Problems

Respiratory Problems

Blood Pressure Problems

Diabetes

Tuberculosis

Rheumatic Fever

Seizures

Bee Sting Allergy

Other

None of the Above

Has your child ever had the following? *

Hospitalizations

Operations

Serious Injuries

Other Health Problems/Illnesses

Allergies to Medications (ie Penicillin, Sulfa, Drugs)

None

Date of Diagnosis

MM

DD

YYYY

Has your child experienced any of the following due to ASTHMA?

Treatment in the ER

Hospitalizations

Have you ever given your child any medications for asthma?

Albuterol

Intal

Ventolion

Pedia Pre

Tedral

Prelone

Proventil

Primatine Mist

Marax

Quiboron

Other

If yes, why?

Medical need (special diet prescribed by a doctor)

Religious, cultural or personal reasons

Have any of your child’s family members been diagnosed with any of the following conditions: *

Asthma

Allergies

Anemia

Blood Disorder

Cancer

Diabetes

High Cholesterol

High Blood Pressure

Heart Attack/Disease

Thyroid Disease

Kidney Disease

Seizures

Migraines

Autism

Depression/Anxiety

Alcoholism/Substance Abuse

ADD/ADHD

Other

None

The above checked condition(s) was diagnosed to the following family member(s).

Mother

Father

Sibling

Grandparent

Aunt

Uncle

Cousin

Other Family Member

If yes to either of the 2 above questions, Do you know if the person had active TB disease or latent TB infection?

TB Disease (Symptoms)

Latent Infection (No Symptoms)

Don’t know

If you answered yes to the above question.

Alacon

Alkohi

Azarcon

Bali goli

Bint al zahab

Coral

Greta

Farouk

Ghasard

Kandu

Kohl

Liga

Litargirio

Lozeena

Pay-loo-ah

Sindoor

Surma

Maria Luisa

Name of Primary Caregiver *

This will serve as your signature.

First Name

Last Name

Name *

First Name

Last Name

Child *

First Name

Last Name

Child DOB *

MM

DD

YYYY

EHS Agreement *

Yes

No, I will find my own outside providers to fulfill EHS screening requirements.

Health Information Release *

I consent that the necessary health information concerning my child may be released to the appropriate agencies assisting in the care of my child and the school that my child will be attending after the infant/toddler program.

Yes

No

Consent *

I, the parent have recieved a description of the above screenings and assessments. This information has been explained to me in a manner which I understand and hereby give my consent for my child to receive these screenings and assessments. I am also consenting to the observation by a mental health professional. I understand that these services are necessary parts of my child's health record. I understand that I will be notified prior to any of the above screenings and any questionable results will be forwarded to me so that together with the Early Childhood staff we can follow-up on any problems.

Yes

No

Parent Name *

My signature affirms my willingness to participate in the Infant Screening Program

First Name

Last Name

Parent *

First Name

Last Name

Child

First Name

Last Name

Child DOB

MM

DD

YYYY

Pre-existing Family Plan *

If there is a pre-existing plan, please sign a Release of Information Form to be retained in the family folder.

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Person

First Name

Last Name

Parent Signature *

First Name

Last Name

Date

MM

DD

YYYY

Name *

First Name

Last Name