Appears in 2 contracts

Samples: Parent Agreement, Parent Agreement

Appears in 1 contract

SLEEPING. Has your child shown any sleeping problems: ❑ Yes ❑ No If yes, please explain: How long does he/she sleep at night? What is his/her sleeping pattern, AM: PM: Do you have any special ways of helping him to go to sleep? ❑ Yes ❑ No If yes please explain: Does your child usually cry when he/she goes to sleep? ❑ Yes ❑ No If yes, please explain: Does he/she cry when they wake up? ❑ Yes ❑ No Does he/she sleep in his own bed/crib? ❑ Yes ❑ No Does he/she sleep in their own room? ❑ Yes ❑ No Does he/she sleep with any special toys/ blankets, etc.? ❑ Yes ❑ No If yes, what are they: FEEDING/EATING Has your child had any feeding/eating problems? ❑ Yes ❑ No If yes what are they? What are his/her favourite foods? INTAKE QUESTIONNAIRE FOR INFANTS, TODDLERS, PRESCHOOL Please complete the appropriate sections and take to your PROVIDER on your first day. What foods does he/she dislike? Are there any allergies or sensitivities to particular foods? ❑ Yes ❑ No If yes, please explain: Are these allergies Anaphylactic? ❑ Yes ❑ No Please inform your agency if your child has Anaphylactic Allergy INFANTS ONLY Is your infant Breastfed? ❑ Yes ❑ No Bottle fed? ❑ Yes ❑ No Do you give you infant a vitamin/mineral supplement regularly? ❑ Yes ❑ No When: Type: Which foods is your infant eating? Vegetables Fruits Cereals Meats Milk/Formula Juices How does your infant eat or drink at home? ❑ in your Arms ❑ high chair ❑ other: Infants 12 months and younger only: Indicate specific feeding instructions including times and amounts: OTHER (indicate N/A to any questions below that don’t apply) How does your child react to new situations such as having you leave them momentarily or to go out? How does they react to strangers? Does he/she usually fuss or protest? Is it a strong protest? How quickly does he recover? INTAKE QUESTIONNAIRE FOR INFANTS, TODDLERS, PRESCHOOL Please complete the appropriate sections and take to your PROVIDER on your first day. What strategies do you use to comfort your child if he/she is upset and/or frightened? How does your child behave when he/she is ill? If your child has a sibling at home, how do they interact or play together? Does your child play quietly in the house? ❑ Yes ❑ No Do you have any special concerns regarding? Discipline: Toilet Training: Do you have any restrictions for types of or time spent viewing/interacting with media (e.g. television, computer, gaming system, etc.)? What kind of experiences do you expect home child care to provide for your child? Do you have any additional comments? Signature or Parent/Guardian Date: NON-PRESCRIPTION CONSENT FORM‌ (FOR SUNSCREEN, CREAMS, OINTMENTS AND OTHER NON-PERSCRIPTION PRODUCTS APPLIED TO SKIN) Child’s Name: DOB: Provider’ Name: Type of Product Reason/Time/ Frequency Amount Phone Before Applying Discontinue if noticing or showing side effects Sunscreen *Do not use sunscreen on infants under 6 months of age ❑ Yes ❑ No Moisturizing Skin Lotion ❑ Yes ❑ No Lip Balm ❑ Yes ❑ No Insect Repellent ❑ Yes ❑ No Hand Sanitizer ❑ Yes ❑ No Diaper Cream ❑ Yes ❑ No Other ❑ Yes ❑ No Other instructions or restrictions: IMPORTANT: All the above products must be: • Supplied by the parent in the original container/box with the child’s name and date on it. • Stored inaccessible to the children. • Recorded in the logbook each time it is used (date, time, amount) I authorize the Provider to apply the above products to my child as per above instructions: Signature or Parent/Guardian: Date: *This form must be completed and signed by the parent and kept in the Children’s Information section of the Provider Manual. When updated or the child withdraws, it must be uploaded onto Wee Track under the child’s profile. EMERGENCY ~~FORMPlease~~ FORM: Please give to your Provider on your child’s first day ~~Provider’s~~ Providers Name: Child’s Name: ~~Child~~Xxxxx’s ~~Date of Birth~~address: Child’s ~~Address:~~ DOB Home Phone Number: Parent 1 Name: Cell #Number: Work #Name: Work Number: Parent 2 Name: Cell #Number: Work #Name: Work Number: Emergency Contacts: persons to be contacted and to whom the child may be released to too if parents are not available Name: Daytime #: Evening #: Name: Daytime #: Evening #: Name: Daytime #: Evening #: Medical ~~History and~~ Information Physician’s Name: Address: Phone #: Are there any known allergies, health, medical, or food restrictions your Provider should know about? Yes No If yes, please explain: ~~History~~ Parent’s Consent: If at any time due to such circumstance as an accident, sudden illness, emergency or medical treatment is required, this may be given, including anesthetic (if necessary) by a private physician or hospital. Written instructions by Xxxxxx and/or Guardian: Parent Signature: Date: Witness: Date: Child Start Date: PHOTO/VIDEO CONSENT FORM Child’s Name: Pictures and/or video of children in care are sometimes taken by Providers and staff of Wee Watch and used in a variety of ways; to keep parents informed and involved, used to show our programming and experience in our Newsletter, website and on social media pages. We would not use your child’s picture or video footage without your consent. This consent is voluntary. Please complete this form so we have a record in your file. I consent for Wee Watch to use photos/video of my child in the following ways: 🞎 Local Agency Newsletter (Distributed via email to Parents and Providers of local Wee Watch Agency only) 🞎 Wee Watch Newsletter (shared with all Parents and Providers via email and posted on xxxxxxxx.xxx) 🞎 Our Website - xxx.xxxxxxxx.xxx 🞎 Social media: Facebook, Instagram, Twitter 🞎 Advertisements and/or displays to promote Wee Watch Note any specific restrictions for any of the items you have selected above: (i.e. if Photos are okay but you do not want video used, or okay with Instagram but not Facebook) OR 🞎 I do not give permission for photos of my child to be used in any format 🞎 I do not give permission for video of my child to be used in any format Signature of Parent: Date: IMMUNIZATION AND HEALTH HISTORY RECORD To be completed by Parent/Guardian Child’s Name: Date of Birth: Parent/Guardian Name: Phone Number#: Doctor’s Name: Doctor’s phone #: IMMUNIZATION AND HEALTH HISTORY 🞏 Please attach a copy of your child’s immunization record with this form List any allergies, serious illness, operations or disabilities: Check off any communicable diseases ~~(as listed in Parent Handbook), has~~ your child has had: ~~None~~ 🞏 Chicken Pox 🞏 Rubella 🞏 Measles 🞏 Mumps ~~Measles~~ 🞏 Whooping Cough ~~Xxxxxxxx Xxxxx Other~~ 🞏 Scarlet Fever 🞏 Other: Parent Signature: Date: (~~specify):~~Incorporated Company) O/A Wee Watch Address: _ Telephone number: Privacy Officer: Area Supervisor CUSTOMER CONSENT FORM (for parents): FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION Privacy of your personal information is an important part of our office providing you with quality day care. We understand the importance of protecting your family’s personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our customers. In this agency, (Area Supervisor) acts as the Privacy Information Officer. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. Attached to this consent form, we have outlined what our office is doing to ensure that: ▪ Only necessary information is collected about your family ▪ We only share your information with your consent ▪ Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols ▪ Our privacy protocols comply with privacy legislation, standards of our regulatory body, and all provincial day care legislation. Do not hesitate to discuss our policies with me or any member of our office staff. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality day care. How Our Office Collects, Uses and Discloses Customer Personal Information Our agency understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information. This office will collect, use and disclose information about you for the following purposes: ▪ To deliver safe and efficient child care ▪ To identify and to ensure continuous high quality service ▪ To assess your child care needs ▪ To enable us to contact you ▪ To establish and maintain communication with you ▪ To allow us to maintain communication and contact with you to distribute child care information ▪ To allow us to efficiently follow-up on child care and billing ▪ To complete and maintain licensing requirements as set out by the provincial government ▪ To complete and maintain purchase of service requirements as set out by the provincial government ▪ To collect unpaid accounts ▪ To assist this office to comply with all regulatory requirements ▪ To comply generally with the law By signing the consent section of this Customer Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your family’s personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your family’s personal information, we will seek your approval in advance. You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process. Consent Form for Parents I have reviewed the information in the customer consent form that explains how your office will use my family’s personal information, and the steps your office is taking to protect this information. I know that your office has a Privacy Code, and I can ask to see the Code at any time. I agree that (Area Supervisor) and her staff can collect, use and disclose my family’s personal information about , as set out in the information about the office’s privacy policies. Signature Print name Date Signature of witness PRESCRIPTION MEDICATION AND CREAMS CONSENT FORM AND RECORD Child’s Name: Xxxxx’s address: Physician’s Name: Physician’s phone #: Name of Medication: Date prescribed: Dosage prescribed: Start date: End date: Times to be given by Provider: Amount to be given by Provider: Storage Instructions (INACCESSIBLE TO CHILDREN): Discontinue medication if you notice any of these side effects: OR, dispense medication as needed 🞎 If as needed, indicate the physical or behavioural symptoms to be observed before administering medication: 🞎 I authorize the administration of the above medication to my child by XXX WATCH Provider as outlined above. Signature of Parent or Guardian Date: DISPENSING RECORD Date Time Given DOSAGE Administered by Comments/Observations The form must be completed and signed by the parent in advance. ALL MEDICATIONS MUST BE SUPPLIED BY THE PARENT **NOTE: This record must be kept in the child’s file at the office for 3 years when the medication is finished September 10, 2019 EMERGENCY INFORMATION & SCHEDULE FOR BACK-UP PROVIDERS Child’s Name: Xxxxx’s address: Child’s DOB Home Phone Number: Parent 1 Name: Cell Number: Work Name: Work Number: Parent 2 Name: Cell Number: Work Name: Work Number: Drop Off Time: Pick Up Time: Emergency Contacts: persons to be contacted and to whom the child may be released too if parents are not available Name: Daytime #: Evening #: Name: Daytime #: Evening #: Name: Daytime #: Evening #: Child’s Daily Routine: for Infants 12 months and under X.X. Xxxxxxx Timing: P.M. Bottles Timing:

Appears in 1 contract

Samples: Parent Agreement

Common use of SLEEPING Clause in Contracts