Positive Parenting at Trinity
A Child Care ~ Preschool Facility
Child’s full name_____________________________________________________________
Date of birth _____________________________
 Parents/Guardians/Custodians with whom the child resides:
Name ___________________________________ Relationship to child __________________
Address __________________________________ Home Phone _________________________
_________________________________________ Cell Phone __________________________
Employer _________________________________Work Phone _________________________
 I hereby give my permission for my child to leave the Positive Parenting Center
with the following persons listed below:
Name ___________________________________ Relationship to child __________________
Home Phone ______________________________Cell Phone __________________________
Employer ________________________________ Work Phone _________________________
Name ___________________________________ Relationship to child __________________
Home Phone ______________________________Cell Phone __________________________
Employer ________________________________ Work Phone _________________________
 Persons to contact in case of emergency if parents are unavailable, and are
authorized to pick up the child:
Name ___________________________________ Relationship to child __________________
Home Phone ______________________________Cell Phone __________________________
Employer ________________________________ Work Phone _________________________
Name ___________________________________ Relationship to child __________________
Home Phone ______________________________Cell Phone __________________________
Employer ________________________________ Work Phone _________________________
 Is there any custody or restraining orders for person(s) who may attempt to pickup or have contact with the child while in the care of the center?
Yes ______ No _______ Name ___________________________________________________
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Information
In the event that my child (listed above) may require medical and/or surgical care while I am
out of the city or unable to be reached, I hereby give my consent for medical and/or surgical
treatment to _____________________ Hospital and Doctor ____________________________
or his/her designee to provide this care. In the event that my child may require dental and/or
dental surgical care while I am out of the city or unable to be reached, I hereby give my consent
for dental and/or dental surgical care to ________________________ Hospital and Doctor
____________________ or his/her designee to provide this care. I agree to pay all the costs
and fees contingent on any emergency medical care and/or treatment for my child as secured or
authorized under this consent. NOTE: Every effort will be made to notify parents/guardians
immediately in case of an emergency. This form will be presented upon admission for
treatment.
Child’s Doctor ____________________________Phone________________ _______________
Address ______________________________________________________________________
Family’s Dentist __________________________ Phone _______________________________
Address ______________________________________________________________________
Date of last tetanus _____________________________________________________________
Known allergies _______________________________________________________________
Present medication ____________________________________ _________________
Religious preference (optional) ___________________________________________________
Insurance company ___________________________ Policy holder’s I.D. _________________
This consent will be in effect for one year beginning (date) _________________ and continuing
while the child is enrolled at this facility.
Parent checked for updates, please initial by corresponding month if no changes are required:
February __________
May __________
August_____________
_____________________________________________________________________________
Signature parent/guardian
Date
_____________________________________________________________________________
Signature parent/guardian
Date
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Activity / Photo Authorization
Child’s Full Name ______________________________________________________________
ACTIVITY AUTHORIZATION
______ Understanding that children learn best by experience, I hereby give my permission for my child to leave
the Positive Parenting Center for educational outings around the Church grounds between Brady Street and
Main Street and 11th Street and 12th Street.
______ Understanding that if we leave the grounds outside of Brady Street and Main Street and 11th Street and
12th Street, we will ask for an additional permission slip to be signed before your child can participate in that
experience.
Parent’s Signature ______________________________________ Date ___________________
Photo/ Video Authorization
______ I hereby give permission for my child to be photographed or video taped while participating at Positive
Parenting at Trinity or in programs or activities affiliated with or for Positive Parenting at Trinity. These photos
or videos can be shared or reproduced for the purpose of educational information, center photo albums,
photographs to be displayed on the walls and in the classrooms at Positive Parenting at Trinity. Photographs can
be printed and sent home to with all children in the photograph. Photographs and video can be used for publicity
purposes in conjunction with local news, news papers, and news paper websites, local news letters, and United
Way Projects. Photographs and video can be used for advertisements for Positive Parenting at Trinity.
Photographs and video can also be posted to www.PositiveParentingPreschool.org and related websites.
______ I prefer that my child not be photographed.
Parent’s Signature ______________________________________ Date ___________________
Parent’s e-mail address: _______________________________________________________
(Please provide if you wish to receive notices of pictures available online and other future notices.)
Information and Daily Routine
Siblings:
Are there other children or adults in the home? Yes ______
(If yes, please list names and birthdays.)
No ______
1. ________________________________________
________________________
2. ________________________________________
________________________
3. ________________________________________
________________________
Discipline
Please explain who disciplines your child when it is necessary and what form of discipline is used.
__________
Who?
__________
Who?
_______________________________________________________
How?
_______________________________________________________
How?
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__________
Who?
_______________________________________________________
How?
Parent’s Insights
What further information about your child would you consider helpful to the staff in understanding your child?
________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Eating:
Does your child have any unusual eating problems or food dislikes? (If yes, please explain.)
______________________________________________________________________________
______________________________________________________________________________
I give my permission for the staff at Positive Parenting at Trinity to post my child’s food allergies in their
facility where all staff members and/or volunteers can view it. This ensures my child’s safety during meal
times. Signature/Date: _____________________________________
Sleeping:
What is your child’s attitude toward waking time? __________________Usual time __________
What is your child’s attitude toward nap time? _____________________Usual time __________
What is your child’s attitude toward bed time? _____________________Usual time __________
Toilet Habits:
How does your child state the need for urination? ________________Is child dependable?_____
How does your child state the need for bowel movement? __________Is child dependable?____
Play and Sociality:
How does your child get along with other children? ____________________________________
Who are your child’s playmates? ____ None ____ Older ____ Younger ____ Girls ____ Boys
What group setting(s) has your child experienced?
_____ Sunday School
_____ None
_____ Child care
_____ Play group
_____ Nursery School
Previous Child Care Facility
Has your child previously attend preschool in another setting? ________
Please list the program name, length of time in care, and if it was an in home setting.
________________________ _________________ ____________________________________________
__________________________________________________________________________ ___________
________________________________________________________ _____________________________
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Personality and Emotional Development:
How does your child show affection? _______________________________________________
What is your child’s usual disposition? ______________________________________________
How does your child accept new people? ____________________________________________
What fears does your child show? __________________________________________________
When does your child feel nervous? ________________________________________________
What nervous habits does your child show? __________________________________________
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Assessment Authorization
Please initial the assessments you would like your child to participate in at Positive Parenting. We will not
share your child’s outcomes with anyone other than yourself.
Focused Portfolio Assessment
This is an ongoing assessment provided to all children enrolled in our program. This assessment focuses on
reaching various milestones. These milestones include the areas of thinking, emotional, social, language, gross
and fine motor, reading, writing, and creativity. This assessment takes place by observing the children in their
natural settings. When a milestone is observed it is recorded by one or more of the following : written
observation, photographs, and/or art work that they have created. Children and parents will receive their
individual portfolios upon leaving Positive Parenting.
____
My child may participate in the Focused Portfolio assessment
Peabody Picture Vocabulary Assessment
This is an assessment that focuses on the words that your child understands but may not use in conversation.
The goal of this assessment is to compare your child’s receptive vocabulary score to the average receptive
vocabulary score for a child the same age. This assessment will provide the parent with an idea of where their
child falls, above average, below average, or average in their receptive vocabulary milestones. This assessment
is completed every 6 months after your child turns 2.5 or one month after their enrolment. Individually children
are shown a group of pictures. They are asked to point to the picture of the single word provided to describe the
picture.
____
My child may participate in the Peabody Picture Vocabulary Assessment.
Visual Letter Recognition Screening
The fall before your child attends kindergarten this screening will take place. Individually children will be asked
to name letters shown to them. There are a total of 60 letters written in lower case, upper case, and type font.
The number correct is recorded. Tin late spring before your child begins kindergarten they will be given the
same screening. Their scores will be compared to their previous score. This is to ensure that your child has an
understanding of written print
____
My child may participate in the Visual Letter Recognition Screening
My child may participate in the above initialed assessments at Positive Parenting.
Parent Signature_________________________________
Date_____________
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CULTURAL, RELIGIOUS, MEDICAL INPUT FORM
Child’s Name _______________________________ Date of Birth
Center__________________________________________________________
1.
Are there any milestones you observed in your family (child losing first tooth, birthday or unbirthday, or adoptive
day, first haircut, first allowance, etc.)?
2.
What kinds of activities does your family do in the community?
3.
Are there any activities that your child cannot participate in because of your culture? If yes, please list:
4.
Are there any activities that your child cannot participate in because of your religious beliefs? If yes, please list:
5.
Are there any activities that your child cannot participate in because of a medical reason? If yes, please list:
___________________________________
Parent signature
___________________
Date
___________________________________
Parent signature
___________________
Date
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Hand Washing Contract
In accordance with best practices, your child is required to wash hands upon arrival prior to signing in or
entering the classroom. It would be in your child’s and families best interest to wash your child’s hands prior to
leaving. This practice too will help to minimize the spread of germs.
The hand washing procedure we are adopting comes from Caring For Our Children: National Health and Safety
Performance Standards, a book published by the American Academy of Pediatrics. Positive Parenting at
Trinity’s hand washing procedure is as follows:
Children and staff members shall wash their hands using the following method:
a) Check to be sure a clean, disposable paper (or single-use cloth) towel is available.
b) Turn on warm water, no less than 60 degrees F and no more than 120 degrees F, to a comfortable
temperature.
c) Moisten hands with water and apply liquid soap to hands.
d) Rub hands together vigorously until a soapy lather appears, and continue for at least 10 seconds.
Rub areas between fingers, around nailbeds, under fingernails, jewelry, and back of hands.
e) Rinse hands under running water, no less than 60 degrees F and no more than 120 degrees F, until
they are free of soap and dirt. Leave the water running while drying hands.
f) Dry hands with the clean, disposable paper or single use cloth towel.
g) If taps do not shut off automatically, turn taps off with a disposable paper or single use cloth towel.
h) Throw the disposable paper towel into a lined trash container; or place single-use cloth towels in the
laundry hamper; or hang individually labeled cloth towels to dry. Use hand lotion to prevent chapping
of hands, if desired.
In order to prevent skin breakdown, we will be making hand lotion available to children as part of the hand
washing procedure. Children will self-administer the lotion with coaching and possible hand over hand
assistance, as needed.
Positive Parenting at Trinity will be utilizing Suave brand lotion for use in the center. A list of ingredients is
available upon request. If your child is allergic to ingredients in Suave, please feel free to supply lotion for your
child to use. A medication authorization form needs to be completed and on file for your child to use an
alternate lotion.
I the parent/guardian of _____________________________ have read and agree to the handwashing procedure,
including the application of Suave lotion to my child’s hands.
____________________________________
Parent/Guardian Signature
_________________
Date
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Positive Parenting at Trinity
A Child Care ~ Preschool Facility
Child Care Service Contract
I understand that tuition is due on Monday at the beginning of each week. I am requesting ____
units to be reserved each week for my child at a rate of $________ per unit. I understand that
the weekly charge remains the same regardless of my child’s attendance. I may alter my
request or withdraw my child without penalty if I give a two-week notice, otherwise tuition is
due. The payee will be responsible for all past due accounts and a 1½% per month late fee, plus
all collection and legal fees. Failure to provide a proper withdraw notice or paying your balance
in full will result in the inability for future enrollment in our program. Failure to pay weekly
tuition by Monday will result in a $5.00 per day late fee charge until bill is paid.
Child’s Name: __________________________________________________________
Please check all times when care is needed:
A.M. Units (7:00 a.m. to 11:30)
P.M. Units (11:30 to 5:30 p.m.)
Monday _______________________
Tuesday _______________________
Wednesday _____________________
Thursday _______________________
Friday _________________________
________________________
________________________
________________________
________________________
________________________
If the parent is at school or more than one location during the days indicated, please
provide us with your class schedule or information allowing Positive Parenting to locate you in
the event of an emergency.
My child’s anticipated meal participation will be:
 7:05 Breakfast
 9:05 am snack
 11:30 Lunch
 3:30 pm snack
Parent’s name:___________________________________ SS#:_____________________
Parent’s Signature ______________________________
Date ____________________
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Positive Parenting at Trinity
A Child Care ~ Preschool Facility
Supplemental Parent Information
Parent/Guardian
Alternate Parent/Guardian
Name: ________________________________
Name: _____________________________
Address: ______________________________
Address: ___________________________
City/State/Zip: _________________________
City/State/Zip: ______________________
Home Telephone: _______________________
Home Telephone: ____________________
Work Telephone: _______________________
Work Telephone: ____________________
Cell Telephone: _________________________
Cell Telephone: _____________________
E-Mail Address: ________________________
E-Mail Address: ____________________
SSN: __________________________________
SSN: ______________________________
Photo ID:
Photo ID
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Positive Parenting at Trinity
A Child Care ~ Preschool Facility
I have received a parent handbook and I have been informed through this book of the
rules and regulations at Positive Parenting at Trinity.
_______________________________________
________________________
Signature
Date
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Positive Parenting at Trinity
A Child Care ~ Preschool Facility
Parent Checklist
For your child to enroll in our facility, we must have the following paperwork:
Immunization Card/Exempt
Physical by medical doctor
Intake Paperwork; 6 pages (front & back)
Copy of Birth Certificate
Application for Free & Reduced Meals
Work/School schedule
(If you receive State Assistance)
Child Care Certificate
(If you receive State Assistance)
Allergy/Food Exempt Statement
(If your child has food allergies)
____
____
____
____
____
____
____
____
In order to begin child care services please provide us with the above items prior to your
child’s start date.
Items Needed
The following check list of items is required when your child begins enrollment:
Blanket
____
(Must fit in tote size: 12”x10”x6”)
____
$15.00 or $25.00 enrollment fee
____
Extra clothing – labeled
____
(For current season)
Diaper/Wipes
____
(Please check your child’s supply often)
Your child will have a place in the bathroom for their extra clothes, diapers and wipes. It will
be your responsibility to place these items in their designated place.
Daily arrival procedure:
All children must be accompanied by their drop off person to sign-in at the children’s sign-in
books, put any items, such as a blanket and/or coats, wash their hands, and then taken to their
family or the appropriate area according to the daily schedule.
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