Referred By

How did you hear about the school? Word of mouth Driving by and seeing the school The bus Online AD

Program Selection * Pre-School - Open Enrollment - Ages 2-5

After School - Up to age 6

DOE - Learning Bridges 3K

DOE - Learning Bridges Pre-K Choose one or more programs to enroll in.

Child's Information

Child's Name * First Last

Nickname

Gender * Male Female

Date of Birth *

Enrollment Date

Primary Home Address * Street Address City ZIP Code

Home Phone *

Child's Primary Residence * Mother

Father

Both

Guardian

Parent/Guardian Information

Mother/Guardian Name * First Last

Mother/Guardian Email *

Mother/Guardian Cell Phone *

Father's Name First Last

Father's Email

Father's Cell Phone

Comments

Payment Option * Private Pay

ACS Voucher

HRA Voucher

DOE - Learning Bridges

Consent * I acknowledge and agree to COVID policy.

Medical Consent release Young Minds in motion will contact your child’s Pediatrician for their medical records. Please provide:

Doctors Name

Doctors Number

Doctors Email Address

Consent I give Young Minds in Motion permission to obtain my child’s medical records for the purpose of enrolling them into school.

Print

Date

Thank You

Young Minds in Motion Disciplinary Procedures & Policies A very important part of the preschool experience is helping children learn how to get along in the world, enjoy being with other children, and follow the direction of an adult other than their parent. A caring and positive approach will be taken regarding behavior management and discipline. The teachers will focus on the positive behaviors of the children and reinforce those behaviors as often as possible. Our goal is to help the children develop self-control and responsibility for their actions.

Young Minds in Motion Disciplinary Procedures & Policies 1. Encouraging children to use their words when having a disagreement with another child facilitating children in their attempts to settle their own disputes.

2. Redirecting behavior when this seems potentially effective.

3. Separating a child from the group (Time-Out) – one minute away for each year of age.

4. Counseling children individually about their behaviors. 5. Making parents aware of disciplinary concerns (Incident Report). Disruptive Behavior distracts from the full benefit of the preschool program and will result in consequences. The following behaviors are considered disruptive: • Requires constant attention from the staff

• Inflicts physical or emotional harm on other children, adults, or self • Disrespects people and materials provided in the program • Consistently disobeys the rules of the classroom • Verbally threatens other students and/or staff • Uses verbal or physical activity that diverts attention away from the group of children.

Discipline Procedures for disruptive behavior Level 1: Student and teacher discussion, and teacher’s procedure of notification to parent through Kinderlime and phone contact. Teacher discusses behavior with the student and student receives an infraction(s) based on their choice(s). Time outs and sitting out an activity. Level 2: Student and teacher discussion, student may possibly receive time to think about their choices, as well as teacher’s procedure of notification to parent through the class behavioral management program. Level 3: Once a child has served 3 time outs, or 3 parent notifications for behavior, a parent/teacher conference will be arranged to discuss positive solutions. Level 4: Parent meeting with administration. Level 5: Suspension –Depending on the infraction (one day up to 5 days). Level 6: Dismissal -When little or no change is evident, and school personnel have exhausted all available means to affect change, and/or the welfare of the other students is endangered, the student will be expelled. This decision rests with the school administration. Children cannot become self-disciplined unless adults teach them right from wrong. At Young Minds in Motion, children will be taught the expectations for correct behavior and encouraged to live and act accordingly. When children know something is wrong, and choose to do it anyway, consequences will follow to communicate that the behavior is not acceptable and will not be tolerated in our school.

Discipline Policy Agreement I have read Young Minds in Motion Disciplinary Policies and Procedures. I have discussed this with my child and agree to comply with the discipline policies and procedures of Young Minds in Motion

Biting Policy Although it is not uncommon for very young children to bite, it is a behavior that is taken very seriously, and is strongly discouraged. When children are older than 24 months, biting is less common. Language is beginning to become the tool of choice, with “No!” and “Mine!” is used most frequently. These verbal warnings alert the teachers that it may be time to intervene, and redirect the playmates involved in another direction. When an older child bites, the preschool’s policy is:

1st offense the child who bites will quickly be placed in “Time Out”, while the teacher comforts the child who has been bitten, and attends to cleaning the bite. Then, the teacher will return to “Time Out” and speak with the offending child about what has happened. The child is reminded that teeth are for eating food & smiling, not for biting. Both sets of parents will be told of the incident. The parent of the child that bit the other student will be asked to come and pick up the child for early dismissal.

the child who bites will quickly be placed in “Time Out”, while the teacher comforts the child who has been bitten, and attends to cleaning the bite. Then, the teacher will return to “Time Out” and speak with the offending child about what has happened. The child is reminded that teeth are for eating food & smiling, not for biting. Both sets of parents will be told of the incident. The parent of the child that bit the other student will be asked to come and pick up the child for early dismissal. 2nd offense The child’s parents will be asked to keep their child at home for 2 days and focus on helping the child understand that biting is unacceptable

The child’s parents will be asked to keep their child at home for 2 days and focus on helping the child understand that biting is unacceptable 3rd offense removal from the program for the remainder of the school year.

Consent I have read Young Minds Biting Policies. I have discussed this with my child and agree to comply with the biting policies and procedures of Young Minds in Motion

Tuition Agreement Form

Tuition Agreement

Private: I understand that my child’s tuition is an ongoing monthly fee and I am responsible for my child’s tuition amount based on his/her scheduled days, regardless of any days my child is ill, on vacation, or does not attend for any other reason. Deposits will be accepted on a case-by-case basis. Deposits are non-refundable.

ACS: I understand that my child’s co-pay is an ongoing weekly fee and I am responsible for my child’s co-payment based on the ACS form. I am responsible for my child’s weekly co-pay fee even if my child does NOT attend for the week or is absent for 1 or more days during the week.

HRA: I understand that my child’s co-pay is an ongoing weekly fee and I am responsible for my child’s co-payment based on the HRA form. If my child attends for one day out of the week I am still responsible to pay the weekly fee.

Payment Schedules You will be billed on Fridays for payments due that Sunday which is for services for the following week. If no payment is made by Monday night, and no arrangements have been made, there will be no service until payment is made. Although your child is not allowed to attend while tuition is unpaid, you are still responsible for payment for the time they are not there. A bill will be sent to you via email and must be paid ONLY via the Procare app.

Private: Late payments and Non-Payments: I understand that payments made after the tenth of the day of the month are considered late and a late fee of $35 will be assessed. I am aware that if the 10th day of the month falls on a weekend/holiday the last day tuition can be paid without a late fee is the last day the center is open before the holiday/weekend.

ACS & HRA: Late payments and Non-Payments: I understand that payments made after the Monday after the previous Friday of the week are considered late and a late fee of $5/day will be assessed. I am aware that if the Friday/Monday of the week falls on a weekend/holiday, the last day that tuition can be paid without a late fee is the day prior to when the center is open before the weekend/ holiday.

All Funding Streams: Returned Checks: I understand that if my tuition check is returned for any reason, I will be charged a processing fee of $25.00. I understand that if Young Minds in Motion receives two or more returned checks from my family, they will no longer accept checks as a method of payment.

All Funding Streams: Delinquent Accounts: I understand that if accounts continue to be delinquent, the center has the right to discontinue services.

Young Minds in Motion does not discriminate based on disability in the admission/access to our program.

Consent I understand and agree with all the aforementioned terms listed in the Tuition Agreement.

Daily ProceduresAgreement Please initial each item below:

I agree to sign the school attendance log when my child arrives in the morning and again when he/she is picked up at the end of the day. No one under the age of 16 is allowed to sign my child in/out of the school.

Illness: I understand that I will be notified by school personnel if my child becomes ill during the day and I agree to make every effort to have my child picked up in a timely manner, as the health and safety of all children is of the utmost importance. If my child is exposed to or contracts a contagious disease, I agree to notify the school and I will make certain that he/she does not return to school without written permission from my child’s doctor.

Withdrawal from Young Minds in Motion: I have the right to withdraw my child from the program at any time; however, I understand that I must provide a 2-week written notice of withdrawal. If this written notification is not received I agree to pay all the tuition for the 2-week period. I understand that if I then choose to re-enroll my child, she/he will only be readmitted based upon space availability and at the current rate of tuition.

At the Director’s discretion, Young Minds in Motion has the right to ask a child to withdraw from our program. A a two-week written notice will be given for your child not to return for the following month.

Inclement Weather/School Closings: I understand that it is the Day Cares’ objective to be open during every regularly scheduled school day; however, there are some specific days during which the school will be closed (i.e. federal holidays). In addition, inclement weather and or natural/national disaster or major building issues may necessitate an immediate school closing. This will not affect my child’s tuition in any way.

Consent I understand and agree with all the aforementioned terms listed in the Daily Procedures.

Emergency Release and Authorized Escorts List To maintain the safety of your children, Parents/Guardians must complete, sign, and return this form to Young Minds in Motion upon enrollment. This form shall be updated periodically or when there are changes in the Emergency Release and Authorized Escort information.

Emergency Release Contacts: Only individuals listed below will be considered as designated emergency release persons. Government-issued ID will be required at the time of pick up. All release persons must be above 16 years of age. Please submit a photo ID of all individuals listed below.

Name

Relationship to Child:

Preferred Contact Information:

Home Address:

Emergency Release

Non- Emergency Release

Name

Relationship to Child:

Preferred Contact Information:

Home Address:

Emergency Release

Non- Emergency Release

Name

Relationship to Child:

Preferred Contact Information:

Home Address:

Emergency Release

Non- Emergency Release

Name

Relationship to Child:

Preferred Contact Information:

Home Address:

Emergency Release

Non- Emergency Release

Name

Relationship to Child:

Preferred Contact Information:

Home Address:

Emergency Release

Non- Emergency Release

Name

Relationship to Child:

Preferred Contact Information:

Home Address:

Emergency Release

Non- Emergency Release

Consent I authorize this child care center to release my child to the individuals I have identified above.

Health Insurance Information

Health Insurance Provider:

Policy #:

Policy Holder Name:

Dental Included? Yes

No

Pediatrician

Pediatricians Number

Child Illness Policy On the average, babies experience eight to ten illnesses a year; preschoolers experience almost as many. We know that managing the demands of work can be challenging when your child is ill. We strive to limit the spread of communicable diseases in our centers and are committed to implementing policies that balance and respect the needs of children, families, and staff in these circumstances. Our Child Illness Policy is based on the Model Health Care Policies developed by the American Academy of Pediatrics. Young Minds in Motion understands that it is difficult for a parent/guardian to leave or miss work; therefore, it is suggested that alternative arrangements be made for occasions when children must remain at home or be picked up due to illness. Exclusion from the center is sometimes necessary either to reduce the transmission of illness or because the center is not able to adequately meet the needs of the child. Mild illnesses are common among children, and infections are often spread before the onset of any symptoms. In these cases, we try to keep the children comfortable throughout the day. Reasons Young Minds in Motion may exclude children include (but are not limited to) the following:

• Illness that prevents the child from participating comfortably in program activities, such as going outdoors.

• Illness that results in a greater need for care than our staff can provide without compromising the health and safety of other children.

• Illness that poses a risk of spread of harmful disease to others

• Severely ill appearance

• Fever of I 00 degrees or above (axillary); IO I or above (orally) or an equivalent measure accompanied by behavior change or other signs and symptoms.

• Fever of I 00 degrees or above (axillary) or IO I or above (orally) in an infant younger than two months; such circumstances should be medically evaluated within an hour

• Fever of I 04° F or greater in a child of any age (requires immediate medical attention)

• Diarrhea; watery stools or decreased form of stool not associated with the change of diet; stool not contained in the diaper; child unable to reach the toilet; or stool frequency that exceeds 2 or more stools above normal for that child.

• Cases of bloody diarrhea and diarrhea caused by Shigella, salmonella, Shiga toxin-producing E coli, Cryptosporidium or G intestinalis must be cleared for readmission by a health care professional.

• Blood or mucus in the stools not explained by dietary change, medication, or hard stools.

• Vomiting more than 2 times in the previous 24 hours (unless the vomiting is determined to be caused by a non-communicable condition and the child is not in danger of dehydration).

• Mouth sores with drooling (unless the child's medical provider or local health department authority states that the child is noninfectious).

• Abdominal pain that continues for more than 2 hours; intermittent abdominal pain associated with fever, dehydration, or other signs of illness.

• Rash with fever or behavioral changes (unless a physician has determined it is not a communicable disease).

• Skin sores weeping fluid and on an exposed area that cannot be covered.

• Purulent conjunctivitis (defined as pink or red conjunctiva with white or yellow eye discharge) until on antibiotics for 24 hours.

• Impetigo until 24 hours after treatment has been started.

• Strep throat (or other streptococcal infection) until 24 hours after treatment has been started.

• Head lice or nits until after the first treatment.

• Rubella, until 7 days after the rash appears.

• Scabies until 24 hours after treatment has been started.

• Chickenpox, until all lesions have dried or crusted (usually 6 days after onset of rash).

• Pertussis (whooping cough) until 5 days of antibiotics.

• Mumps, until 5 days after onset of parotid gland swelling.

• Measles, until 4 days after onset of rash.

• Hepatitis A virus until I week after onset of illness or jaundice or as directed by the health department (if the child's symptoms are mild).

• Tuberculosis, until the child's medical provider or local health department, states the child is on appropriate treatment and can return.

• Any child determined by the local health department to be contributing to the transmission of illness during an outbreak.



For your child's comfort, and to reduce the risk of contagion, we ask that children be picked up within 1.5 hours of notification. Until then, your child will be kept comfortable and will continue to be observed for symptoms. Children need to remain home for 24 hours without symptoms before returning to the program unless the center receives a note from the child's medical provider stating that the child is not contagious and may return to the center. A note from the child's medical provider is required before any child can return to school if they have been absent for two consecutive days or more regardless of the illness. Children who have been absent may return when:

• They are free of fever, vomiting, and diarrhea for a full 24 hours.

• They have been treated with an antibiotic for a full 24 hours.

• They are able to participate comfortably in all usual program activities, including outdoor time.

• They are free of open, oozing skin conditions and/or excessive mucus unless

• the child's medical provider signs a note stating that the child's condition is not contagious, and

• the involved areas can be covered by a bandage without seepage or drainage through the bandage.

• For those children previously suffering from diarrhea or excessively lose bowel movements, readmission can occur when toilet-trained children no longer have toileting accidents and diapered children cease from having diarrhea.



If a child is excluded because of a reportable communicable disease, a note from the child's medical provider stating that the child is no longer contagious is mandatory. Ultimately, the final decision on whether to exclude a child from the program due to illness will be made by the Director at Young Minds in Motion based on the safety or concern for all of the other children. Note: Please be aware that Notes allowing for a child's return to the center after exclusion due to illness must originate from the child's medical provider. A note was written and signed by the child's parent/guardian who is also a physician is not acceptable.

Consent I agree with the above terms.

Photo Consent Form Photos are taken daily in our classrooms to capture the milestones that your child achieves. Photos are used for weekly newsletters, our website (both public and private), quarterly parents and family newsletters, and printed marketing materials. Please indicate your permission for consent and sign below.

Young Minds in Motion Parents and Family Newsletter (distributed within center, not visible to the public) Yes

No

Young Minds in Motion secured Parent Portal website (members only, not visible to the public) Yes

No

Social media and company website (visible to the public) Facebook, Twitter, etc. Yes

No

Printed Marketing Materials (visible to the public) Flyers, brochures, magazines, advertisements, etc. Yes

No

Consent I agree to the privacy policy.

NEW STUDENT SUPPLY LIST Upon entry, the following items are required.Please make certain that all items are clearly labeled with your child’s name, so we can assure that it will be used for your child only. List is subject to change.

•Potty Training Pull-Ups with Velcro on the Sides)

• Baby Wipes

• Seasonal Change of Clothing (pants, shirt, socks, underwear, etc.)

• Two (2) Crib Size Sheets and Two (2) Blankets for Nap-time (23" x 51")

• (1) Pair of Crocs /Garden Shoes

• One supply box with supplies. The student's teacher will provide a list.

Consent I agree with the above terms.

Child Health History Form Hospitalization, Accidents, Illnesses and Medication

Was child ever hospitalized or operated on? Yes

No

Has child ever had a serious accident? Yes

No

Has child ever had a serious illness? Yes

No

Is your child currently taking medication? Which medication? Yes

No

Comments

Has your child ever had or currently have any of the following concerns or does your child complain about any of the following? (Please check all that apply) Frequent sore throat

Frequent cough

Urinary infections

Stomach pain, concerns

Difficulty seeing

Currently wear glasses

Ears/hearing

Seizures, convulsions

Comments

Has your child ever had or does your child currently have any of the following diseases? (Please check all that apply) Asthma

Bleeding tendencies

Diabetes

Epilepsy

German Measles

Measles

Heart/Blood Vessel Disease

Liver Disease

Rheumatic Fever

Sickle Cell Disease

Boils or Hives

Chicken Pox

Eczema

Mumps

Whooping Cough

Polio

Comments

Allergies & Other Conditions

Select if the following applies to your child: This child does NOT have a food allergy that requires restrictions or medications.

This child does NOT have any allergies.

Name of Allergen (pea nuts, eggs, shellfish, etc.)

Previous reactions (rash, lip swelling, nausea/ vomiting, difficulty breathing, anaphylaxis;etc.)

Dietary Restriction Complete avoidance

Avoid in these specific forms:

Others

Dietry Restrcitions Others

Emergency Treatment, if required * Epinephrine

Benadryl

Other

Emergency Treatment, if required * : Others

(2). Name of Allergen (pea nuts, eggs, shellfish, etc.)

(2). Previous reactions (rash, lip swelling, nausea/ vomiting, difficulty breathing, anaphylaxis;etc.)

(2). Dietary Restriction Complete avoidance

Avoid in these specific forms:

Others

(2). Dietry Restrcitions Others

(2). Emergency Treatment, if required * Epinephrine

Benadryl

Other

(2). Emergency Treatment, if required * : Others

(3). Name of Allergen (pea nuts, eggs, shellfish, etc.)

(3). Previous reactions (rash, lip swelling, nausea/ vomiting, difficulty breathing, anaphylaxis;etc.)

(3). Dietary Restriction Complete avoidance

Avoid in these specific forms:

Others

(3). Dietry Restrcitions Others

(3). Emergency Treatment, if required * Epinephrine

Benadryl

Other

(3). Emergency Treatment, if required * : Others

(4). Name of Allergen (pea nuts, eggs, shellfish, etc.)

(4). Previous reactions (rash, lip swelling, nausea/ vomiting, difficulty breathing, anaphylaxis;etc.)

(4). Dietary Restriction Complete avoidance

Avoid in these specific forms:

Others

(4). Dietry Restrcitions Others

(4). Emergency Treatment, if required * Epinephrine

Benadryl

Other

(4). Emergency Treatment, if required * : Others

**If child requires medication for this allergy, please complete the Medication Consent Form for each medication required, and provide the parent with prescription(s) for additional medication to be kept at the childcare program site.

Any allergies to foods, medication, environment, or animals?

Does any of the above affect your child’s everyday activities?

Are there any other conditions that may affect everyday activities that wasn’t discussed above?

Comments

Pregnancy/Birth History

Did mother have any health problems during pregnancy, delivery? Yes

No

Did mother visit a physician fewer than 2 times during pregnancy? Yes

No

Was your child born outside of the hospital? Yes

No

Was your child born more than 3 weeks early or late? Yes

No

Were there any concerns with the child during or immediately after delivery? Yes

No

Was the hospital stay extended? Yes

No

Comments

Consent I agree with the above terms.

Hospitalization, Accidents, Illnesses and Medication

This child does NOT have a food allergy that requires restrictions or medications. Yes

No

This child does NOT have any allergies. Yes

No

Name of Allergen (pea nuts, eggs, shellfish, etc.)

Previous reactions (rash, lip swelling, nausea/ vomiting, difficulty breathing, anaphylaxis;etc.)

Name of Allergen (pea nuts, eggs, shellfish, etc.)

Previous reactions (rash, lip swelling, nausea/ vomiting, difficulty breathing, anaphylaxis;etc.)

Dietary Restriction

Name of Allergen (pea nuts, eggs, shellfish, etc.)

Previous reactions (rash, lip swelling, nausea/ vomiting, difficulty breathing, anaphylaxis;etc.)

Dietary Restriction

Name of Allergen (pea nuts, eggs, shellfish, etc.)

Previous reactions (rash, lip swelling, nausea/ vomiting, difficulty breathing, anaphylaxis;etc.)

Dietary Restriction

**If child requires medication for this allergy, please complete the Medication Consent Form for each medication required, and provide the parent with prescription(s) for additional medication to be kept at the childcare program site. **

Does this child have an allergist? Yes

No

Name of Allergist:

Phone Number

Health Care Provider (MD, DO, NP, PA):

Date

Print Name of Health Care Provider:

Address

Fax Number

Phone Number

Consent I agree to the privacy policy.

Brief Respiratory Questionnaire (BRQ)

In the past 12 months, has your child experienced wheezing or whistling in the chest, or a cough that lasted more than a week? Yes

No

In the past 12 months, how many times did your child experience wheezing or whistling in the chest, or a cough that lasted more than a week?Number of nights (record “0” if none)

In the past 12 months, how many nights did your child have trouble sleeping because of wheezing or whistling in the chest, or a cough that lasted more than a week?

Please tell us if a doctor, medical care provider, or clinic ever used that name below to describe your child’s condition.

Asthma Yes

No

RAD (Reactive Airway Disease) Yes

No

Bronchitis or bronchiolitis (bron-kee-oh-lite-iss) Yes

No

Asthmatic or Wheezy Bronchitis Yes

No

Wheezing Yes

No

In the past 12 months, has a doctor, medical provider or clinic prescribed any medicine, inhaler, nebulizer, or breathing machine treatments for any of these conditions, that is for asthma, reactive airway disease, bronchitis or bronchiolitis, asthmatic or wheezy bronchitis, or wheezing? Yes

No

In the past 12 months, how many times did your child have an emergency visit to a doctor, clinic or an emergency room for asthma, wheezing, cough, chest tightness, or shortness of breath?

In the past 12 months, how many times did your child have to stay overnight in the hospital for asthma, wheezing, cough, chest tightness, or shortness of breath?

Is your child currently under the care of a doctor, nurse, or clinic for asthma, wheezing, cough, chest tightness, or shortness of breath? Yes

No

Does anyone in your household smoke? Yes

No

Consent I agree to the privacy policy.

NEW YORK STATE DEPARTMENT OF HEALTH Child and Adult Care Food Program

Income Eligibility Form for Child Care Centers

CHILD CARE CENTER NAME

Print the name of the child(ren) enrolled in this child care center

Complete SECTION A if anyone in your household

1. Participates in the Supplemental Nutrition Assistance Program (SNAP)

2. Receives Temporary Assistanceto Needy Families (TANF)

3. Participates in the Food Distribution Program on Indian Reservations (FDPIR) OR

4. Is a foster child



SECTION A

SNAPCase #

TANF #

FDPIR #

Names of Foster Children

** An adult household member must sign the application before it can be approved. After reading the following statement and the statement on the back, sign below **

Consent I certify tha the above information is true. I understand that the center will get Federal funds based on the information I give

FOR SPONSOR USE ONLY

CACFP Agreement #

Total Number of Household Members (INCLUDING FOSTER CHILDREN, IF APPLICABLE)

Total Household Income $

Date of Determination

Complete SECTION B

Complete SECTION B if no one in your house hold participates in SNAP, receives TANF, participates in FDPIR or if none of the children enrolled in the child care center is a foster child.

SECTION B

List all household members below. Include yourself and all adults and children NOT listed above, even if they do not receive income. Then list all income received last month in your household in the Brackets. Gross income includes earnings from work, pensions, retirement, Social Security, child support, foster child's personal income, and any other sources of income.

HOUSEHOLD MEMBER NAME (Include the MONTHLY GROSS SALARY in the brackets)

An adult household member must sign the application before it can be approved. After reading the following statement and the statement on the back, sign below.

LAST FOUR (4) DIGITS OF SOCIAL SECURITY NUMBER

Consent I certify that the above information is true and that all income is reported. I understand that the center will get Federal funds based on the information I give.

Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this form. You do not have to give the information, but if you do not, we can not approve the participant for free or reduced-price meals. You must include the last four digits of the Social Security Number of the adult household member who signs the form. The SocialSecurity Numberisnotrequiredwhenyou: apply on behalf of a foster child; provide a SNAP, TANForFDPIRnumber; or when you indicate that the adult household member signing the form does not have a SocialSecurity Number. We will use your information to determine if the center is eligible for free or reduced-price meal reimbursement and for administration and enforcement of the program.

INSTRUCTIONS FOR COMPLETING DOH-3688

Definition of Income

Income means income before deductions for income taxes, social security taxes, insurance premiums, charitable contributions, and bonds, etc. It includes the following: (1) monetary compensation for services, including wages, salary, commissions or fees; (2) net income from non-farm self-employment; (3) net income from farm self-employment; (4) Social Security payments; (5) dividends or interest on savings or bonds, income from estates or trusts or net rental income; (6) unemployment compensation; (7) government civilian employee or military retirement, or pensions or veteran’s payments;(8) private pensions or annuities; (9) alimony or child support payments; (10) regular contributions from persons not living in the household; (11) net royalties; (12) military benefits received in cash, such a housing allowance except if you are in the Military Housing Privatization Initiative; and(13)another cash income.

Definition of Household

Household means family as defined in Section 226.2. Family means a group of related or non-related individuals who are not residents of an institution or boarding house, but who are living as one economic unit.

INSTRUCTIONS FOR PARENTS OR GUARDIANS Write in the name of the child care center in the space provided.

Print the name of each child in your household who attends this child care center.

Section A: If anyone in your household participates in the Supplemental Nutrition Assistance Program (SNAP), receives Temporary Assistance for Needy Families (TANF) or participates in the Food Distribution Program on Indian Reservations (FDPIR), complete Section A only. Write down the SNAP, TANF, or FDPIR number(do not use your ACS or DSS child care subsidy number). Then sign and date the form and return it to the daycare center

. Foster children: If your household includes a foster child who is in child care, write in the names of the foster children.

Section B: Complete this section if you did not complete Section A. Write in your name and the names of all other adults and children living in the household, including unrelated people, even if they do not have any income. Do not include the children in childcare who are listed at the top of the form.

Enter the amount of income each person received last month, before taxes or anything else was taken out. Refer to the Definition of Income and the Definition of Household, above. If any amount last month was more or less than the usual, write in that person’s usual income.

The last four digits of the Social Security Number of the adult signing the certification are required. If you do not have a Social Security Number, write none. The form must be signed by an adult member of the household.

INSTRUCTIONS FOR CENTERS AND SPONSORS

The For Sponsor Use Only section is to be completed, signed, and dated by center or sponsor staff. The sponsor/center representative must review the income eligibility form and ensure that it is completed as indicated in the instructions above. Then indicate the following:

The CACFP Agreement Number

The total number of household members – This item does not have to be completed if the parent completed Section A. Add those indicated in Section B (if completed)to the children enrolled in child care and the number of foster children, if applicable.

TotalHouseholdIncome – This item does not need to be completed if the parent completed Section A.Indicate the total monthly income as calculated from Section B. If the parent chooses not to disclose income, the form must be categorized as paid.

Number of Free, Reduced or Paid –

Compare the total household income and the total number of household members with the current year’s Income

Eligibility Guidelines (CACFP-3687) to determine if the household should be categorized as Free, Reduced, or Paid. Use the appropriate column on the CACFP-3687 to categorize their income. For example, if the parent indicated biweekly income, multiply this amount by 26 to determine yearly income. Incomplete forms (missing signatures, income information, last four digits of Social Security Number or SNAP, TANF, or FDPIR numbers) are categorized in the paid category. The income eligibility form is valid until the last day of the month one calendar year from the date it is signed by the household member. For For example, a form signed on May 12, 2014, is valid until May 31, 2015.

FAMILY MEDICAL HISTORY FORM ALLERGIES ( include the allergic reaction in brackets )

ALLERGY ( ALLERGIC REACTION )

MEDICATIONS ( include the Dosage and times per day in the given format )

MEDICATIONS - DOSAGE - TIMES PER DAY

Additional Information

FAMILY MEDICAL HISTORY

Mother Alcohol/Drug Abuse

Asthma

Cancer

Emphysema (COPD)

Depression/Anxiety

Bipolar/Suicidal

Diabetes

Early Death

Heart Disease

High Cholesterol

High Blood Pressure

Kidney Disease

Stroke

Thyroid Disease

Migraines

Others

Father Alcohol/Drug Abuse

Asthma

Cancer

Emphysema (COPD)

Depression/Anxiety

Bipolar/Suicidal

Diabetes

Early Death

Heart Disease

High Cholesterol

High Blood Pressure

Kidney Disease

Stroke

Thyroid Disease

Migraines

Others

Brother Alcohol/Drug Abuse

Asthma

Cancer

Emphysema (COPD)

Depression/Anxiety

Bipolar/Suicidal

Diabetes

Early Death

Heart Disease

High Cholesterol

High Blood Pressure

Kidney Disease

Stroke

Thyroid Disease

Migraines

Others

Sister Alcohol/Drug Abuse

Asthma

Cancer

Emphysema (COPD)

Depression/Anxiety

Bipolar/Suicidal

Diabetes

Early Death

Heart Disease

High Cholesterol

High Blood Pressure

Kidney Disease

Stroke

Thyroid Disease

Migraines

Others

Child Alcohol/Drug Abuse

Asthma

Cancer

Emphysema (COPD)

Depression/Anxiety

Bipolar/Suicidal

Diabetes

Early Death

Heart Disease

High Cholesterol

High Blood Pressure

Kidney Disease

Stroke

Thyroid Disease

Migraines

Others

Maternal GM Alcohol/Drug Abuse

Asthma

Cancer

Emphysema (COPD)

Depression/Anxiety

Bipolar/Suicidal

Diabetes

Early Death

Heart Disease

High Cholesterol

High Blood Pressure

Kidney Disease

Stroke

Thyroid Disease

Migraines

Others

Maternal GF Alcohol/Drug Abuse

Asthma

Cancer

Emphysema (COPD)

Depression/Anxiety

Bipolar/Suicidal

Diabetes

Early Death

Heart Disease

High Cholesterol

High Blood Pressure

Kidney Disease

Stroke

Thyroid Disease

Migraines

Others

Paternal GM Alcohol/Drug Abuse

Asthma

Cancer

Emphysema (COPD)

Depression/Anxiety

Bipolar/Suicidal

Diabetes

Early Death

Heart Disease

High Cholesterol

High Blood Pressure

Kidney Disease

Stroke

Thyroid Disease

Migraines

Others

Paternal GF Alcohol/Drug Abuse

Asthma

Cancer

Emphysema (COPD)

Depression/Anxiety

Bipolar/Suicidal

Diabetes

Early Death

Heart Disease

High Cholesterol

High Blood Pressure

Kidney Disease

Stroke

Thyroid Disease

Migraines

Others

Others

Signature *