District Child Care Application

District Child Care Application

2009-2010

Student’s Name: ______

Last First Middle/Nickname

Mailing Address: ______Age______

School: ______Grade: ______Full-Time: ______Part-Time: ____ DOB______

Homeroom Teacher: ______

Parent/Guardian’s Name: ______

Home Phone #______Mom’s Cell #______Dad’s Cell #______

Mothers Work #______Supervisor/Ext: ______Place of Employment______

Fathers Work # ______Supervisor/Ext: ______Place of Employment______

List four other persons who should be contacted in case of an emergency and/or to pick-up your child.

Name: ______Name: ______

Phone #______Cell #______Phone #______Cell #______

Name: ______Name: ______

Phone #______Cell #______Phone #______Cell #______

List other siblings enrolled in the program: ______

Is your child allergic to any medications or foods? Yes _____No _____ If so, please list______

______

List physical handicaps, restrictions, and/or impairments: ______

The Montgomery County School System and/or staff will not be held responsible for any expense or liability incurred by accident or illness beyond that covered by insurance that is carried by the school system Students, their parents, and employees of the Montgomery County Board of Education are hereby notified this school district does not discriminate on the basis of race, color, national origin, age, religion, martial status, sex or handicap in employment, educational programs, vocational programs, or activities set forth in Title IX, Title VI, & Section 504. Any person having inquiries concerning the above is directed to Mr. Rick Mattox, Montgomery County Board of ED., 700 Woodford Drive Mt. Sterling, KY 40353/859-497-8760

CONSENT FOR MEDICAL/SURGICAL CARE/

EMERGENCY TREATMENT

AND CHILD’S MEDICAL INFORMATION

In presenting my son/daughter for diagnosis and treatment

Name:______for______

{ } Mother { } Father { } Legal Guardian { } Son { } Daughter

of____ years of age; hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment, and blood transfusions, by authorized members of the hospital staff or their designees, as may in their professional judgment be necessary.

I hereby acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on child’s condition.

I have read this form and I certify that I understand its contents.

We/I hereby give my consent to Montgomery County Schools Child Care Program and After School Programs who will be caring for our child ______for the period ______to ______to arrange for

(Name of Child)

routine or emergency medical/surgical/dental care and treatment necessary to preserve the health of our (my) child.

We/I acknowledge that we are (I am) responsible for all reasonable charges in connection with care and treatment rendered during this period.

Name: ______Family Physician: ______#______

Address: ______Pediatrician: ______#______

______Surgeon: ______#______

Telephone #: ______Orthopedist: ______#______

Name of Health Insurance Carrier: Child’s Allergies, if any:

______

______Date of last tetanus booster: ______

Group No ______Medicines child is taking: ______

Agreement No ______

______

Signature: ______

Mother, Father or Legal Guardian Date

Witness: ______

Date

IN CASE OF EMERGENCY I CAN BE REACHED AT:

FY 2010

ENROLLMENT FORM

CHILD AND ADULT CARE FOOD PROGRAM

Name of Participant(s) / Date of Birth

Dear Parents,

This child care center participates in the Child and Adult Care Food Program (CACFP). This program assists the center in providing nutritious meals to your child. Under the CACFP regulations, the center may NOT charge you a separate fee for meals that are claimed for reimbursement.

In an effort to improve our program, we periodically conduct household contacts, where we ask parents to provide input and to verify attendance of their children at this day care center. If you have any questions regarding the completion of this form, please contact ______(sponsor name) at ______(phone number). Please fill in ALL of the following information:

Name of Parent/Guardian
Home Address:
Home #: / Cell #: / Work #:

Is the participant in full time attendance? ______Yes ______No

What are the days the participant is normally in care?

____Monday ____Tuesday ____Wednesday ____Thursday ____Friday ____Saturday ____Sunday

What are the hours the participant regularly spends at the center? _____am/pm to _____am/pm

(example — 7:30 am. to 4:00 pm.)

What meals is the participant served while at the center?

___Breakfast ___AM Snack ___Lunch ___PM Snack ___Supper ___Late Night Snack

Do you supply any food to the center for the participant’s meals due to medical or religious reasons? If Yes, please list foods supplied. ______

______

*The CACFP enrollment form is based on the federal fiscal year that begins October 1. The date of enrollment should be 10/1/09 if the participant attends before or by October 1, 2009. After October 1, 2009, list the participant’s actual first date of attendance.

______

Parent/Guardian and/or Client Signature Date

______

Determining Official Signature Date Participant’s Date of Enrollment

If you have any questions about the CACFP and its administration, you may contact Paul McElwain, Division Director, or Denise Hagan, Community Nutrition Branch Manager, at 502/564-5625 or at the following address: Nutrition and Health Services, Kentucky Department of Education, 2545 Lawrenceburg Road, Frankfort, KY 40601.

Note: All other CACFP Enrollment Forms are Obsolete