Early Care and Education Center Enrollment Form | Children's Services of Roxbury

In addition to the Early Care and Education Center form below, please download and fill out these state forms:

Please complete and submit the form below. Note that additional forms will need to be completed upon child’s acceptance.

Enrollment Application Form for Early Care and Education Center

Step 1 of 11

Name of Child(Required)

First Middle Initial Last

Nickname

Age(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender Assigned at Birth(Required)

Female

Male

Gender Identity(Required)

Female

Male

Other

Child's Photo

Max. file size: 5 MB.

Please upload a recent photo of your child, if available.

Child's Primary Language(Required)

Parent/Guardian's Primary Language(Required)

Home Email Address(Required)

Home Phone(Required)

Child's Address(Required)

Street Address Address Line 2 City State ZIP Code

Who lives with the child?(Required)

Mother

Father

Guardian

Select all that apply

Days to Attend(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Primary Contact Information

Name of Parent/Guardian #1(Required)

Relationship to Child for Parent/Guardian #1(Required)

Address of Parent/Guardian #1

Same as Child’s Address

Address of Parent/Guardian #1(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone Number for Parent/Guardian #1(Required)

Secondary Phone Number for Parent/Guardian #1

Email Address for Parent/Guardian #1(Required)

Is Parent/Guardian #1 Currently Employed?(Required)

Yes

Employer for Parent/Guardian #1

Work Hours for Parent/Guardian #1

Employer's Address for Parent/Guardian #1

Street Address Address Line 2 City State ZIP Code

Work Phone for Parent/Guardian #1

Work Phone Extension # for Parent/Guardian #1 (if applicable)

Name of Parent/Guardian #2

Relationship to Child for Parent/Guardian #2

Address of Parent/Guardian #2

Same as Child’s Address

Address of Parent/Guardian #2

Street Address Address Line 2 City State ZIP Code

Primary Phone Number for Parent/Guardian #2

Secondary Phone Number for Parent/Guardian #2

Email Address for Parent/Guardian #2

Is Parent/Guardian #2 Currently Employed?

Yes

Employer for Parent/Guardian #2

Work Hours for Parent/Guardian #2

Employer's Address for Parent/Guardian #2

Street Address Address Line 2 City State ZIP Code

Work Phone for Parent/Guardian #2

Work Phone Extension # for Parent/Guardian #2 (if applicable)

Parent/Guardian Signature(Required)

Today's Date(Required)

MM slash DD slash YYYY

Transportation Plan and Authorization

Child's Name(Required)

First Middle Initial Last

Child is transported to program by(Required)

(Parent) Public Transportation

Parent/Guardian

Parent-Contracted Transportation Company

Other

Describe Other Transportation

Transportation Company Name

Name of Bus Driver

Phone Number of Bus Driver

My Child Will Arrive at the Program(Required)

Parent Drop-off

Supervised Walk

Public/Private/Van

Private Transportation arranged by Parent/Guardian

Other

My Child Will Depart from the Program(Required)

Parent Pickup

Supervised Walk

Public/Private/Van

Private Transportation arranged by Parent/Guardian

Other

Emergency Contact Information

Please list the persons you would like contacted (in order of priority) if you cannot be reached in case of emergency. Check the “Emergency Contact and Release” box, as the persons listed will also be authorized to pick up or accompany the child for the purposes of medical treatment. We will not release a child to anyone (other than the parent) under the age of eighteen (18), including siblings. Additionally, please list the persons you would like to be authorized for pick-up only on a given day (i.e., babysitter). For these persons, check the “Release Only” box. For the safety of your child, we will request all authorized release persons with whom staff are not familiar to provide government-issued photo required by Department of Early Education and Care (EEC) licensing regulations.

Emergency Contact 1

Emergency Contact 1 Name(Required)

Emergency Contact 1 Relationship to Child(Required)

Emergency Contact 1 Home Phone(Required)

Emergency Contact 1 Cell Phone(Required)

Emergency Contact 1 Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Emergency Contact 1 Employer

Emergency Contact 1 Work Hours

Emergency Contact 1 Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact 1 Work Phone

Emergency Contact 1 Work Phone Extension (if applicable)

Emergency Contact 1 Permissions(Required)

Emergency Contact and Release

Release Only

Emergency Contact 2

Emergency Contact 2 Name(Required)

Emergency Contact 2 Relationship to Child(Required)

Emergency Contact 2 Home Phone

Emergency Contact 2 Cell Phone

Emergency Contact 2 Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Emergency Contact 2 Employer

Emergency Contact 2 Work Hours

Emergency Contact 2 Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact 2 Work Phone

Emergency Contact 2 Work Phone Extension (if applicable)

Emergency Contact 2 Permissions(Required)

Emergency Contact and Release

Release Only

Emergency Contact 3

Emergency Contact 3 Name(Required)

Emergency Contact 3 Relationship to Child(Required)

Emergency Contact 3 Home Phone

Emergency Contact 3 Cell Phone

Emergency Contact 3 Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Emergency Contact 3 Employer

Emergency Contact 3 Work Hours

Emergency Contact 3 Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact 3 Work Phone

Emergency Contact 3 Work Phone Extension (if applicable)

Emergency Contact 3 Permissions(Required)

Emergency Contact and Release

Release Only

If you want a person who is not identified above to pick up your child, you must notify CSR staff in advance, in writing. Your child will not be released without prior authorization. In the event you call a pick-up authorization into the program because you are unable to submit your authorization in writing, we will use your personal information from this packet to verify your identity.

For all children’s safety, it is critical to use your secured access to enter the building and sign in your child according to EEC licensing regulations. To ensure the safety of our CSR’s staff and children, please do not share your secured access with anyone else. If you must pick up your child after closing tyime, you will be charged a late fee per every 15 minutes or portion of 15-minute period, per child, until the child(ren) is/are picked up. Per EEC licencing regulations, we may be required to contact local authorities/Department of Children and Families (DCF) after a certainn amount of time. Please see your Program Director for additional information.

Authorization for Medical Treatment of a Minor

In the event of a medical issue requiring a physician's care, would you like us to call your family physician?(Required)

Yes

Physician's Name

Physician's Phone

Physician's Address

Street Address Address Line 2 City State ZIP Code

Child's Name(Required)

First Middle Initial Last

Date of Birth(Required)

MM slash DD slash YYYY

Authorization(Required)

I authorize staff in Children’s Services of Roxbury Early Care and Education Center who are trained in the basics of First Aid/CPR to give my Child (First Aid/CPR) when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to the preferred hospital/clinic listed below, and to secure necessary medical treatment for my child.

I authorize the staff as stated above.

Preferred Hospital/Clinic for Acute Care and Emergency Care(Required)

Dentist Name(Required)

Dentist Practice/Clinic Name(Required)

Dentist Phone

Dentist Address(Required)

Street Address Address Line 2 City State ZIP Code

Health Insurance Provider(Required)

Health Insurance Policy Number(Required)

Secondary Health Insurance Provider

Secondary Health Insurance Policy Number

Allergies to Drugs, Foods, or Other

Please list any special medications or pertinent information

Permission for Toothbrushing(Required)

I give permission for my child to brush teeth during program hours.

I do not want my child to brush teeth during program hours.

Parent/Guardian Signature(Required)

Date(Required)

MM slash DD slash YYYY

Permission for Sunscreen(Required)

I give the Center permission for my child to apply sunscreen when needed.

I do not want my child to apply sunscreen during school.

Parent/Guardian Signature(Required)

Date(Required)

MM slash DD slash YYYY

Permission for Evacuation

I (we) also authorize the program to evacuate in case of emergency. I understand that the evacuation site is posted in the school and listed in the Parent Handbook.

Parent/Guardian Signature(Required)

Date

MM slash DD slash YYYY

Authorization for Transportation and Field Trips

The program may plan carefully arranged, supervised special trips for the children away from the program that do not require bus transportation. You will be notified in advance of all trips. These include children taking walks and infants strolling in their buggy. I give the school permission to take my child on these field trips.

Parent/Guardian Signature(Required)

Date

MM slash DD slash YYYY

Parents/Guardians of Children Ages 4 Years Old and Older Only

I give the school the permission to transport my child for the purposes of field trips that require bus transportation and/or transportation to or from his or her local schoo. (You will be notified in advance of all trips.) By signing below, I affirm that my child is at least 4 years old and weighs 40 pounds or more.

Parent/Guardian Signature(Required)

Date

MM slash DD slash YYYY

Infants (less than 12 months old)

Did the child experience any complications at or before birth or require any extended hospital stay (more than 2 days beyond birth)?

Yes

If yes, please explain

Please provide medical documentation. Accommodations may require an Enrolling Children with Special Needs Packet.

Has the child experienced any respiratory issues that require medication, breathing treatments or other special accommodation?

Yes

If yes, please explain

Please provide medical documentation. Accommodations may require an Enrolling Children with Special Needs Packet.

Parent/Guardian Signature(Required)

Date

MM slash DD slash YYYY

Child Profile: Developmental History and Background Information

You know your child better than anyone else in the world! You have observed your child on a day-to-day basis and are uniquiely qualified to share your insight about your child’s development with us. Please take a moment to complete this profile, as the information will help us know your child better and to meet his or her individual needs.

Today's Date(Required)

MM slash DD slash YYYY

Child's Current Age(Required)

Name(Required)

First Middle Initial Last

Date of Birth(Required)

MM slash DD slash YYYY

With whom does the child reside? Please list names and relationships to child for all adults and the names and ages of other children.(Required)

Who also cares for your child(ren)?(Required)

What language is spoken in your home?(Required)

When did your child begin speaking or using words?(Required)

What would you like most for your child to experience with us?(Required)

How would you describe your child (personality characteristics)?(Required)

What do you enjoy the most about your child?(Required)

What are your child's play interests (preference for creative, dramatic, or construction play)?(Required)

How does your child express frustration?(Required)

Does your child have any particular fears?(Required)

How does your child comfort himself/herself?(Required)

How do you discipline your child?(Required)

What are the foods your child likes best?(Required)

What are the foods your child likes least?(Required)

What are your child's mealtime routines at home?(Required)

How many hours of sleep does your child receive at night?(Required)

Does your child need to be awakened in the morning to attend the program?(Required)

What is your child's sleeping arrangements? Check appropriate answers.(Required)

Own room

Shares room

Sleeps in crib

Sleeps in bed

Who shares your child's room?(Required)

What are your child's bedtime rituals?(Required)

Does you child nap during the day?(Required)

Yes

How long does your child usually nap?(Required)

For Non-infant enrollment only: Does your child need a comfort item for a nap?(Required)

Yes

What is the specific comfort item?(Required)

Is your child toilet-trained?(Required)

Yes

Explain:

What language do you use to discuss toileting in your house?(Required)

Has your child had previous preschool experiences?(Required)

Are you available to help us with field trips or other special events?(Required)

Do you have a special interest or hobby you would like to share with the children?(Required)

What family or cultural traditions are important in your home?(Required)

Would you be willing to share these traditions with the children?(Required)

Is there anything else you would like us to know about your child that would help us better meet their needs?

Parent Signature(Required)

Today's Date (also at top?)(Required)

MM slash DD slash YYYY

Medical History

Child's Name(Required)

First Middle Initial Last

Date of Birth(Required)

MM slash DD slash YYYY

Height(Required)

Weight(Required)

Hair Color(Required)

Eye Color(Required)

Distinguishing Marks(Required)

Medication that will be administered regularly at the school(Required)

Special Dietary Needs(Required)

Is you child able to walk?(Required)

Yes

Explain:

Can your child effectively communicate his or her needs?(Required)

Yes

Explain:(Required)

Does your child have any medical or physical needs?(Required)

Does your child have any allergies?(Required)

Yes

My child has allergies to:

Medications

Food

Other

Describe other allergies:

Describe all allergens and the reaction your child experiences to each one.

Are any of the allergies severe or life-threatening?

Yes

Please provide special instructions in the event of an exposure.

Does your child have any allergies? Please explain.(Required)

Please provide special instructions concerning any other illnesses, as necessary:

Late Pickup Policies

It is important for children in the childcare center to be picked up on time. First and foremost, our concern is for the child(ren) in our care. A child comes to depend on being picked up a certain time. A different schedule, without warning can cause anxiety in children. We are dedicated to making the child’s day as enjoyable and comfortable a; possible. Also, we need to honor the personal schedule and procedure of our center. For these reasons this Late Pick-Up Policy has been developed:

Please be on time to pick up your child/children or meet the bus.
If the parent/guardian will be later than the scheduled time, please call the childcare center, It is the parent/ guardian will be later than the scheduled time, please call the childcare center, It is the parent/guardian responsibility to know the address and telephone number to the child care center.
Parents/guardians who are late picking up their child/children after 5:30 pm will be charged a late
fee of 51 ,00 per minute. For example, if you arrive at 5:35 the fee is $5.00.
If parent/guardian emergency contact people ca.-u1ot be reached within 30 minutes, we will then contact the Department of Children and Families (DCF) (formerly the Department of Social Services) and 911. A social Worker will come to the childcare center to pick up the child/children and attempt to locate the parent/guardian.
We will do everything we can to reach the parent/guardian and emergency contact people before calling DCF AND 911. However, please note that it is the responsibility of the parent/guardian to be sure the child will be picked up on time. It is important for the center to have the updated names and telephone numbers of all emergency contacts. We will not release the child to anyone unless they have a valid picture ID.
Late fees are to be paid by the following morning before your child will be admitted for the day. Otherwise, the center may terminate your child/children with a two-week notice.

If you have any questions, please call the Center Director at 617-989-9461.

The Late Pick-up Policy has been explained to me, and I have read the above and understand that I must adhere to the Late Pick-up Policy.

Parent/Guardian Signature(Required)

Today's Date(Required)

MM slash DD slash YYYY

Healthcare Policies

Children’s Services of Roxbury Understands that it is difficult for a parent/guardian to leave or miss work, therefore, it is suggested that alternative arrangements be made in case of illness. If your child has any of the following symptoms, we will contact you to pick up your child front the center (within 1 hour) both to provide comfort to your child and to prevent contagion of other children, your child must be kept home for 24 hours (SYMPTOM FREE) before returning to school. In cases of contagious illness (or suspected contagious illness) a doctor’s note will be required before your child can return1 to school.

Temperature of 100 degrees (Temporal)
Vomiting
Diarrhea, (more than once for Toddlers and Preschooler, and three times for Infants)
Any suspicious rash
Colored nasal discharge (if transmission cannot be controlled)
Any contagious illness
Any symptoms requiring one-to-one care and or causing severe discomfort
Any illness accompanied by open, oozing bacterial infections and/or severe bloody diarrhea
Ringworm
Hacking cough

When returning your child to Children’s Services of Roxbury after and illness. please remember:

Your child must be free from fever, vomiting and dia.-rhea for 24 hours (without symptoms) prior to returning to school.
Any child prescribed an antibiotic must take it for 24 hours before returning to school.
Any contagious illness requires a doctor’s statement that u.’ie child is not contagious prior to returning to school.
Your child must be able to participate in all activities upon returning (including outdoor times).

POLICY ON PRESCRIPTION MEDICATIONS

Always require a note signed by the parent/guardian and written order of physician
The note must specify both the dosage and the time to be administered.
A new note is needed each time a medication is prescribed.
The medication must have a current pharmacist label, in the original bottle. Label must include nan1e of medication, child’s name, dosage, frequency, of intake, date prescription filled, expiration date along with name, and number of the physician.

POLICY ON NON-PRISCRIPTION MEDICATIONS

A note is required and signed by both the parent/guardian and the pediatrician.
The note can cover an extended period of time no longer than 2 months
The parent/guardian must request in writing, specific instructions how the medication should be administered, specifying time and dosage
Non-prescription ointment, diaper creams, and topical lotions require only a note signed by the parent/guardian, specifying time and dosage (not to exceed 3 months)

Parent/Guardian Signature(Required)

Today's Date(Required)

MM slash DD slash YYYY

Photo Release Statement

I hereby authorize the staff of Children’s Services of Roxbury to publish images of my child (photographs & video) for use in publications, newspaper, event eds, promotional videos, CSR brochures, CSR website, and social media sites managed by CSR.

I will not file a claim or hold Children’s Services of Roxbury and or its employees responsible for any unwanted attention or claims as a result of my child’s participation in the activities above.

I hereby relinquish any right that I may have to examine or pre-approve photographs and/or videos before they are published. I trust that CSR will exercise good judgment and display the best image of my child for business and promotional purposes only.

I understand that I will not receive royalties or other financial compensation for the use of my child’s im2g: 2nd that CSR will have unlimited use of the photographs and/or video.

As the parent/legal guardian of the child listed below, I confirm that I have the auditorily to allow CSR to use my child’s image for business and promotional Purposes only.

Finally, I acknowledge that my participation is voluntary, end confirm that I have not been forced to sign this photo release statement.

Child's Name(Required)

First Middle Initial Last

Date of Birth(Required)

MM slash DD slash YYYY

Parent /Guardian Signature(Required)

Today's Date(Required)

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Water Play/Sprinkler Permission Form

During the summer, Children’s Services of Roxbury Earl Care and Education Center has many activities involving water. These include, but are not limited to:

Water sensory table
Water spray bottles
Playground sprinklers
Neighborhood playground sprinklers

Upon signing this form, you agree that your child is allowed to participate in water activities.

Please send in the following:

Bathing suits
Water shoes
Change of clothing (your child will need a full set of change of clothes)
Towel
Shower cap (if you do not want your child’s hair to get wet)

PLEASE WRITE YOUR CHILD’S NAME ON ALL CLOTHING, ETC.

Child's Name(Required)

First Middle Initial Last

Parent/Guardian Signature(Required)

Today's Date(Required)

MM slash DD slash YYYY