Handbook — Growing Mindfully

Parent Handbook

November 2022

Mindful Moments, Inc.

DBA Growing Mindfully

Tax ID: 88-1911177

750 N St.

Sacramento, CA 95814

750 N St.

Sacramento, CA 95814 www.growingmindfully.orgTables of Contents

I. About Mindful Moments

A. About Us ………………………………………………………………………..

B. Our Mission ………………………………………………………………….…

C. Our Philosophy …………………………………………………………….….

II. Attendance

A. Ages Served ……………………………………………………………….…..

B. Weekly Schedule ………………………………………………………….…..

C. Absences, Appointments, Early Pickups …………………………….…..

D. Holidays …………………………………………………………………….…..

III. Program and Curriculum

A. Meals …………………………………………………………………………….

B. Supplies ……………………………………………………………………..….

C. Parent Communications & Involvement ……………………………...…..

D. Emergencies ……………………………………………………………………

E. Daily Activity Schedule ……………………………………………………….

F. Field Trips and Events ………………………………………………………..

G. Illness, Medication, and Immunizations …………………………………..

H. Guidance Policy ……………………………………………………….……….

I. Placement Procedures & Parent Rights ………………………….……….

IV. Tuition & Fees

A. Weekly Rates …………………………………………………………………..

B. Fees ……………………………………………………………………………...

C. Methods of Payment ………………………………………………………….

D. Enrollment Priorities ………………………………………………………….

E. Discounts ……………………………………………………………………….

V. Forms

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750 N St.

Sacramento, CA 95814 www.growingmindfully.orgI. Introduction

A. About Us

! Mindful Moments Incorporated (MM)/(DBA of Growing Mindfully) is a for-profit

mixed age group Childcare Organization dedicated to helping raise happy,

resilient, and emotionally nurtured children.

B. Our Mission

! To provide a safe, cognitively challenging, and emotionally nurturing

environment for our students to aid them in becoming active and present

participants in our society.

C. Our Philosophy

! Mindful Moments is a play-based early learning program that serves students

ages 0 through 5. Our Infant & Toddler program follows the teachings of the

RIE (Resources for Infant 'Educarers') philosophy while our Preschool program

follows the “Learn through Play” developmental curriculum approach.

! Infant-Toddler RIE Philosophy

! The RIE Philosophy is respect for and trust in the infant to be an initiator,

an explorer, and, a self-learner. At Mindful Moments we will strive to

support this philosophy by providing an environment for our infants and

toddlers that is physically safe, cognitively challenging and emotionally

nurturing.

! Our staff will be trained to allow our children time for uninterrupted play

and the freedom to explore and interact with the other children enrolled.

All children will be active participants in their daily routine rather than

passive recipients. Staff will be trained to step back an observe the

children in their care whenever possible in order to understand his or her

individual needs. Each classroom will provide consistency and clearly

defined limits and age appropriate expectations to develop discipline.

! In addition to the RIE Philosophy, we also believe in introducing

mindfulness into our classrooms even at this early stage in life.

Mindfulness is the practice of cultivating present moment awareness of

750 N St.

Sacramento, CA 95814 www.growingmindfully.org

WWW.MINDFULMOMENTS.COMthoughts, emotions and physical sensations by integrating our breathing,

stretching, and focusing on relaxation techniques into their daily schedule.

By doing this, children will develop emotional resilience and self-regulation

skills that will lead to a calmer and more engaged classroom.

! Preschool Developmental “Learn through Play” Philosophy

! Children develop self-motivation and the ability to make their own choices

through play and investigational experiences. Through this curriculum

children will learn to balance individual freedom with social co-operation,

negotiation and, responsibility for the welfare of others. They will develop

the ability to reflect and learn from their successes and their own

mistakes. This in turn will build courage and confidence in themselves as

learners.

! Developmental Curriculum takes the children’s interests and uses them as

the predominant means for their lessons and learning experiences. Mindful

Moments staff will be trained the observe the children in their care and

learn their individual interests to shape their lesson planning. This method

of teaching ensures all children have equal opportunity to learn happily

and successfully while also creatively challenging and encouraging them to

explore their true interests.

! In addition to the Developmental Curriculum, we also believe in

introducing mindfulness into our classrooms. Mindfulness is the practice of

cultivating present moment awareness of thoughts, emotions, and

physical sensations by integrating breathing, stretching, and focusing on

relaxation techniques into their daily schedule. By doing this, children will

develop emotional resilience and self-regulation skills that will lead to a

calmer more engaging classroom environment.

! Discipline Approach

! Our discipline approach is a combination of redirection and mindfulness.

Helping to raise happy, compassionate, and responsible children requires

both love and limits.

750 N St.

Sacramento, CA 95814 www.growingmindfully.org! With both redirection and mindful discipline practices we use 5 essential

elements for children to thrive:

! Unconditional love, space for children to be themselves, mentorship,

healthy boundaries, and mistakes that create learning and growth

opportunities.

! Our staff will be trained on setting limits with love, working with difficult

emotions and forgiveness through compassion. This relationship-centered

approach will support the children we care for by developing emotional

intelligence, self-discipline and resilience- qualities we believe all children

need for living an authentic and meaningful life.

II. Attendance

A. Ages Served/Categories Served

! 0 years thru the age of 5 years, with no restrictions or limitations based on child

needs.

B. Weekly Schedule

! Hours of Operation

! Monday - Friday

! 7:00AM - 6:00PM (PST)

C. Absences and Early Pick-ups

! Absences

! Should your child be absent from school we ask for 24 hours’ notice in the

form of email to the Program Director/CEO.

! If this absence is due to illness, please include this in the notice so we

may properly notify parents as needed.

! Early Pickups

! If you will be picking your child up early, please inform the Program Director

upon drop-off so we may properly prepare your child for release at that time.

D. Termination

! Mindful Moments reserves the right to terminate contract upon discretion.

Reasons for termination are subject but not limited to the following:

750 N St.

Sacramento, CA 95814 www.growingmindfully.org! Violation of clauses within this handbook or any agreements made

between MM and the family.

! Though extremely rare, if a child continues to inflict physical harm to

himself or others despite corrective actions.

! Failure to meet payment agreements or carrying of a past-due balance

more than once in a 12-month period.

E. Holidays

! Mindful Moments will be closed in observation of the following holidays:

! New Year’s Day

! Martin Luther King Jr. Day

! President’s Day

! Cesar Chavez Day

! Memorial Day

! Independence Day

! Labor Day

! Veterans Day

! Thanksgiving Day

! Day after Thanksgiving

! Christmas Day

! Inservice Day

! Annually on the Friday prior to Cesar Chavez Day, the school will be closed

and all staff will report for an onsite or remote training for further

educational development & best-practice reinforcement.

! Teacher Collaboration Days

! Mindful Moments will also close the first Monday of every month at 4pm

for teacher collaboration days.

III. Program and Curriculum

A. Meals

750 N St.

Sacramento, CA 95814 www.growingmindfully.org750 N St.

! Mindful Moments will serve 2 snacks per day. These snacks are included with

tuition and served to all students at no additional cost.

! Mindful Moments does not have a fully-functional kitchen, and as such, most

snacks will be pre-packaged and parents will be required to prepare and pack

lunches for their children on a daily basis.

! For health & safety purposes, we are a nut-free facility, and any foods which

contain or are exposed to nuts are strictly prohibited.

! Mindful Moments will also provide a “Breakfast Club,” which is an optional

service for students. This will be a supplementary cost of $35/month per

student (or $50 per family) who participates. Certain dietary needs can be

accommodated for $50/month.

! Mindful Moments also provides vegetarian & allergy-friendly snack options to

children who have special needs or medically-confirmed allergies at an

additional surcharge.

! These meals will be separately cooked in a sanitized environment to ensure

the safety of all children.

B. Supplies

! Mindful Moments will provide the following for each child:

! Nap Mats

! Breakfast (with Breakfast Club Subscription)

! Two Snacks

! Bibs/Spoons/Bowls

! We ask that parents provide the following for their children upon their first day

of attendance:

! Blanket

! Two sets of additional/spare clothes

! One Water Bottle/Cup

! Food Substitutions (Allergy-Related)

! Diapers & Baby Wipes (Not Provided by Mindful Moments)

! Bottles with Formula or Breast Milk (Labeled with Child’s Name and Date)

Sacramento, CA 95814 www.growingmindfully.org! Baby Food/Snacks (Infants Only)

C. Parent Communications & Involvement

! Brightwheel App

! Mindful Moments is proud to integrate Brightwheel into our school program

at no additional cost to our parents.

! Brightwheel is a newly developed application that provides parents with real-

time updates on their child’s development, photos, and communications all

accessible via a mobile app. See Brightwheel One-Pager attached separately.

! Mindful Moments neither owns nor is affiliated with Brightwheel and your use

of the application is governed by their End-User Licensing Agreement.

! Sign-In/Out Procedures

! Parents will be required to sign-in and sign-out their children upon arrival

and departure from the facility.

! Sign-in/out will be performed via Brightwheel on a tablet in the front

lobby.

! Parents will be assigned a unique 4-digit pin that they will enter on the

tablet when they arrive/depart.

! Weekly Communications

! Mindful Moments strives to ensure that all parents, children, and staff are

aware of the day to day operations that take place at the center. Weekly

emails will be sent to all parents enrolled from the CEO and/or Director every

Monday.

! These emails will provide day-to-day expectations for the following week.

It will also include any reminders or information about forms being due or

needing updating.

! In addition to the weekly emails, parents will have real-time updates and

communication with Mindful Moments staff via their BrightWheel app.

! Annual Parent Meeting

750 N St.

Sacramento, CA 95814 www.growingmindfully.org750 N St.

! In September, Mindful Moments’s CEO and/or Program Director, along with

site staff may host an annual parent meeting. This meeting will be a time to

go over and discuss:

! Curriculum of each program

! Discipline procedures

! Health Care Policies

! Enrollment forms and protocol

! Forms that need to be updated

! Waitlist procedures

! Children transitions

! Potty Training

! Program Nutrition

! BrightWheel functions and programing

! Sign-in/out Procedures

! Meeting the Staff

! Parent Questions on items discussed during the meeting

! These meetings, if hosted, will be mandatory and all parents unable to attend

will be subject to a $25 compliance fee.

! Quarterly Parent Meetings

! Quarterly meetings may be offered to all families enrolled at Mindful

Moments as a means to discuss ongoing child development and best

practices to continue at home with their children.

! Parent meetings are a time for parents to see samples of their children’s

work, speak directly with their child’s teacher, ask questions about their

child specifically and, get handouts on areas needing improvement at

home to either move up in each group at our school or be better prepared

for their kindergarten transition.

! Parents will be notified and offered time slots for these meeting two weeks

prior to them happening. Mindful Moments will ensure that all parents will

have the opportunity for their meeting upon their request.

Sacramento, CA 95814 www.growingmindfully.org! Child Assessments

! All staff at Mindful Moments will be responsible for maintaining child

assessments & reports through their Bright Wheel application on their group

of children.

! All assessment areas needed will be worked into the teachers’ lesson plans

every three months to update and maintain an accurate account of where

each child is physically, social-emotionally, cognitively and, language &

Literacy.

! All assessments will be confidential. Staff will be encouraged to answer

any parent questions about their child’s development and offer advice on

areas to work on at home.

! Parent Participation and Classroom Engagement

! At Mindful Moments we love parent participation and offer it on an elective

basis.

! Parents who wish to participate in the classroom or on field trips must have a

clean medical assessment and negative TB test within the last year to be

eligible.

! Parent Concerns & Complaints

! Parents are actively encouraged to bring up any concerns or complaints

about the center or staff directly to the CEO and or Director as soon as

possible.

! All Parents are provided direct lines of communication with the CEO/Director

with their concern or to set up a date/time to discuss in person.

! During that time both parties are encouraged to be open and willing to

truly hear each concern to reach a resolution when needed/possible.

! If a concern needs further action, the CEO/Director will set up next steps

and/or meetings to continue action and dialogue.

D. Emergencies

! All families are required to submit a minimum of three local contacts who must

be readily available to provide care for the child in case of an emergency.

750 N St.

Sacramento, CA 95814 www.growingmindfully.org! Upon enrollment, parents are required to provide MM consent to seek medical

treatment in the event of an emergency.

! In the event of an emergency resulting in school evacuation, Mindful Moments

will follow the procedures set forth in the “Emergency and Disaster Plan” visibly

posted in all rooms of the facility. This form depicts each staff members role

and responsibility in case of an emergency.

! MM will also host monthly evacuation drills to ensure efficacy in these

procedures.

! Parents will be notified once all children are safe and accounted for at the

designated “safe spot”, within 30 minutes of the occurrence.

! Our schools “safe spot” will be across the street at Capitol City Tower Lofts,

Capitol City Tower Parking Garage, and/or Capitol City Tower Lots. The

Director will be responsible for carrying out the school’s emergency bag

which will contain extra diapers, wipes, water, snacks, tissues, activities,

change of clothes in various sizes, and a first aid kit.

! Incidental Medical Services (IMS) Plan of Operation

! Form attached separately to this handbook.

! For minor injuries such as cuts, scrapers, bites, falls, and bruises that occur at

the school, MM may administer ice and/or band-aids as needed. A “Band-aid

Report” will subsequently follow including information pertinent to the incident.

! This form will indicate when the incident happened, how it happened, who

witnessed the incident, who is reporting the incident and where on the body

the injury occurred.

! All staff and parents will be required to sign these reports.

! Copies of this report will be placed into the child’s school file.

! If an injury involves blood or leaves a mark that is deemed as ‘not-serious’

the parents will be notified after the child is cleaned up and back to his/her

daily routine.

! Parents may or may not be asked to come down and console or look at the

injury.

750 N St.

Sacramento, CA 95814 www.growingmindfully.org

WWW.MINDFULMOMENTS.COM! Should a dental emergency arise, parents will be called and notified

immediately and asked to assess the injury to determine a course of action.

! In the event of an “Unusual Incident,

” an unusual incident report will be filled

out by the Mindful Moments staff and parents will be notified immediately and

licensing will be informed within 24 hours. These types of incidents are as

follows:

! This form will be given to the family and is to be given to the child’s doctor at

their appointment.

! The form will be returned to the Mindful Moments Director within 2 business

days and sent to licensing per their requirements.

! The following incidents would be considered unusual: Broken bone, sprained

body part, and anything requiring stitches.

E. Daily Activity Schedule

1. Infants

! Infants tend to make their own schedule and refrain from following any

specific outline. These tendencies are averted in the toddler room where they

begin to learn this structuring.

2. Toddlers

! 7:00AM - 9:00AM: Welcome, Table Activities, & Breakfast (Diapers Changed)

! 9:00AM - 10:00AM: Circle & Small Group Activity

! 10:00AM - 10:15AM: Snack Time

! 10:15AM - 12:00PM: Indoor & Outdoor Play (Diapers Changed)

! 12:00PM - 2:30PM: Nap, Indoor Quiet Time (Diapers Changed)

! 2:30PM - 3:00PM: Outdoor Time

! 3:00PM - 3:15PM: Snack Time

750 N St.

Sacramento, CA 95814 www.growingmindfully.org! 3:15PM - 4:30PM: Indoor & Outdoor Play (Diapers Changed)

! 4:30PM - 6:00PM: Closing Activities & Preparation for Opening Staff

3. Preschool Room

F. ! 7:00AM - 8:30AM: Welcome, Table Activities, & Breakfast (Diapers Changed)

! 8:30AM - 9:00AM: Outside Time

! 9:00AM - 10:00AM: Circle & Small Group Activity

! 10:00AM - 10:15AM: Snack Time

! 10:15AM - 11:30AM: Indoor & Outdoor Play (Diapers Changed)

! 11:30AM - 11:45AM: Group Circle

! 11:45AM - 12:00PM: Clean-up

! 12:00PM - 2:30PM: Nap Time, Quiet Activities (Diapers Changed)

! 2:30PM - 3:00PM: Outdoor Time

! 3:00PM - 3:15PM: Snack Time

! 3:15PM - 4:30PM: Indoor & Outdoor Play (Diapers Changed)

! 4:30PM - 6:00PM: Closing Activities, Preparation for Opening Staff,

Internal/External Communications

Naps, Transportation, Field Trips, and Events

! Naps will be provided daily to children, and MM will provide a quiet and safe

environment for children to rest. Cots are provided to toddler & preschool

children, whereas cribs will be provided to infants.

! Mindful Moments will not provide to/from transportation.

! Lead Teachers will be expected to plan and execute monthly field trips or

extracurricular activities (approved by CEO/Director).

! Any field trips or guest speakers will be funded by the parents themselves

based on divided cost.

! Permission Slips will be sent to parents two weeks prior to any activity that

requires children to leave the school’s premises.

! Reminders will be sent one week prior to event for those parents who

have not submitted their permission.

750 N St.

Sacramento, CA 95814 www.growingmindfully.org750 N St.

! Field Trip transportation will be provided by parents who wish to volunteer.

Parents may elect to drive their child in addition to other children.

! Parents who volunteer to transport children other than their own will be

subject to a background check, medical and TB clearance, verification of

immunization record, and active liability insurance with sufficient policy

limits. Parent volunteers must provide immunization records for MMR, Tdap,

and flu, TB test, and statement of good health.

G. Illness, Medication, and Immunizations

! If a child has a fever exceeding 100.5F or any symptoms of illness the child will

be sent home and able to return upon completing medication and if they no

longer require 1-on-1 care.

! Symptoms may include: excessive runny nose, rashes, coughing,

sneezing, conjunctivitis, mouth sores, vomiting, diarrhea, or complaints of

aches & pains.

! In the event of an allergic reaction at the school, the following steps will be

followed by Mindful Moments staff:

! MM Director will be informed of the issue immediately.

! Child will be removed from the classroom and taken to a safe area away

from other children.

! Upon assessment, the child’s parents will be called and informed of the

reaction along with a summary of what the child ate that day.

! Depending on the severity of the reaction, medical authorities may be called

as a preventative measure.

! Should medical authorities arrive to the facility prior to the child’s parents,

a Mindful Moments staff member will accompany the child to the hospital

until parents arrive.

! Should a child have special needs for a known allergy (i.e. Epipen) or have

medication requirements, the parents will be required to disclose this

information on a medical release form upon enrollment and/or provide a

consent for medical treatment. Failure to disclose this information releases MM

from any liability resulting from lack of care administration.

Sacramento, CA 95814 www.growingmindfully.org! Epipen’s or other medical devices will be kept with the signed administer

form from the doctor in a locked medication box in the classroom which

the child resides.

! In addition to the formal First Aid/CPR training we require our staff to

attend, staff will receive a formal training on how to use the device prior

to the child’s first day of enrollment at MM.

! Medical treatment will only be provided upon receipt of concise instruction

from a medical professional alongside a signed consent for medical

treatment.

! All children must have the required immunizations as set forth by State Law.

Form IMM-230 is attached with full details of these requirements.

! All children must have a clean medical assessment and provide a negative TB

test within the last year prior to enrollment.

H. Guidance Policy

! Our discipline approach is a combination of redirection and mindfulness.

Helping to raise happy, compassionate, and responsible children requires

both love and limits.

! Under no circumstance will MM ever use the following discipline practices:

! Corporal Punishment (i.e. spanking, hitting)

! Yelling/Screaming

! Withholding food or any vital necessities

! Time-outs

! With both redirection and mindful discipline practices we use 5 essential

elements for children to thrive:

! Unconditional love, space for children to be themselves, mentorship,

healthy boundaries, and mistakes that create learning and growth

opportunities.

I. Child Placement Procedures

! Upon an offer of enrollment, MM will conduct interviews with parents and an

initial child readiness assessment to ensure that a child receives the

750 N St.

Sacramento, CA 95814 www.growingmindfully.orgappropriate care and attention based on their current physical and emotional

development. MM will also provide the child's parent or authorized

representative with information about the child care center that shall at least

include the child care center's admission policies and procedures, activities,

services, regulations, hours and days of operation, fees, procedures to be

followed should the child become ill or injured while at the child care center,

and procedures for conducting inspections for illness.

J. Child & Parent Rights

Child Rights – Children have the right:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and

equipment to meet his/her needs.

(3) To be free from corporal or unusual punishment, infliction of pain, humiliation,

intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature,

including but not limited to: interference with daily living functions, including eating,

sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical

functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the

licensee of the provisions of law regarding complaints including, but not limited to, the

address and telephone number of the complaint receiving unit of the licensing agency and

of information regarding confidentiality.

(5) To be free to attend religious services or activities of his/her choice and to have visits

from the spiritual advisor of his/her choice. Attendance at religious services, either in or

outside the facility, shall be on a completely voluntary basis. In Child Care Centers,

decisions concerning attendance at religious services or visits from spiritual advisors shall

be made by the parent(s), or guardian(s) of the child.

(6) Not to be locked in any room, building, or facility premises by day or night.

(7) Not to be placed in any restraining device, except a supportive restraint approved in

advance by the licensing agency.

Parent Rights – Parents have the right:

(1) Enter and inspect the child care center without advance notice whenever

children are in care.

(2) File a complaint against the licensee with the licensing office and review

the licensee’s public file kept by the licensing office.

750 N St.

Sacramento, CA 95814 www.growingmindfully.org(3) Review, at the child care center, reports of licensing visits and

substantiated complaints against the licensee made during the last three

years.

(4) Complain to the licensing office and inspect the child care center without

discrimination or retaliation against you or your child.

(5) Request in writing that a parent not be allowed to visit your child or take

your child from the child care center, provided you have shown a certified copy

of a court order.

(6) Receive from the licensee the name, address and telephone number of the

local licensing office.

I. Needs and Services

! All families will be required to complete a Needs and Services plan upon

enrollment to ensure that MM is appropriately aligned with any special needs

and feeding requirements a child may have.

IV. Tuition & Fees

A. Weekly Rates

B. Fees

! All applicants will be subject to a non-refundable application fee of $60.00

per child -or- $80.00 per family. After first-time registration, parents will be

charged $45 for one child or $65 per family for their annual re-enrollment

each September.

750 N St.

Sacramento, CA 95814 www.growingmindfully.org! A late fee of $25 will be charged to any unpaid tuition on the Wednesday of

each week.

C. Methods of Payment

! Mindful Moments will accept the following methods of payment:

! Cash/Check

! Checks are to be made payable to: Mindful Moments

! ACH Transfer (Autopay via Brightwheel)

! Credit Card

! AutoPay via brightwheel (with processing fee)

D. Enrollment Priorities

! Mindful Moments Employees – 1st Priority

! Local Building State Employees – 2nd Priority

! State Government Employees – 3rd Priority

! Private Applicants - 4th Priority

E. Discounts

! A Sibling Discount of 10% will be available to those who have a sibling

already attending Mindful Moments.

! This discount will be applied to the eldest sibling.

F. Licensing

! Mindful Moments is fully-licensed and adheres to regulations set forth by DSS

Community Care Licensing

By signing this document, I hereby agree to all terms and expectations set forth.

_____________________________________ _______________________________________

Parent Signature Date MM Signature Da

750 N St.

Sacramento, CA 95814 www.growingmindfully.orgMINDFUL MOMENTS HEALTHCARE POLICIES

If your child has any of the following conditions or symptoms, we will contact you to pick up your child from the center

(within 1/2 hour) in order to prevent contagion transfer to other children and staff and to provide comfort to your child.

• Fever accompanied by other symptoms. (Temperature of 100.5F Orally)

• Any rash suspicious of contagious childhood disease

• Vomiting

• Uncontrolled productive cough (raising phlegm)

• Any skin rash, lesion or wound with bleeding or oozing of clear fluid or pus

• Conjunctivitis, also called "pink eye", with white or yellow discharge.

• Mouth sores with drooling

• Any illness or condition requiring one-on-one care

• Scabies, head lice, or other infestations

• Constant, uncontrolled nasal discharge of yellow/green mucous

• Any contagious illness which is reportable to the Department of Public Health

After a child was excluded for any of the above reasons or if your child has been ill at home, in order to return to the

program the following conditions must be met:

• The child may not attend the next day and the child must be free from fever, vomiting, diarrhea (without

symptoms) for a full 24 hours.

o Re-exhibiting of any symptoms will result in immediate secondary dismissal from program.

• The child must be free of open, oozing skin conditions unless:

o A health care provider signs a note stating that the condition is not contagious

o The involved area(s) can be covered by a bandage without seepage of drainage through the bandage.

• A child excluded because of lice, scabies or other infestation may return 24 hours after treatment is begun with

a note from a doctor* stating that the child is larvae-or nit-free.

• If a child was excluded because of a reportable contagious illness, a doctor's note stating that the child is no

longer contagious is required prior to re-admission.

Each State publishes a listing of communicable diseases (such as measles, tuberculosis; whooping cough, etc.) which

must be reported to the Department of Public Health upon diagnosis.

The final decision to exclude and re-accept a child into the program remains with Mindful Moments.

_____________________________________ _______________________________________

Parent Signature Date Director Signature Date

750 N St.

Sacramento, CA 95814 www.growingmindfully.orgCHILD ADMISSION AGREEMENT

This Child Admission Agreement (“Agreement”) shall be effective as of the date the Parent(s) sign

below by and between Mindful Moments Incorporated (“MM”) and the individual(s) identified as

the Parents/Guardian below (the “Parents”).

Name of Parent/Guardian: ______________________________ Phone Number: ______________

Relationship to Children: _______________________________

Name of Parent/Guardian: ______________________________ Phone Number: ______________

Relationship to Children: _______________________________

Name(s) of Child(ren):

Name of Emergency Contact: ____________________________ Phone Number: ______________

Relationship to Children: _______________________________

WHEREAS, children of the Parents, as identified above (the “Children”), wish to utilize the

services of MM (the “Services”) to care for the Children, and MM desires to provide the Services.

NOW, THEREFORE, the parties, in consideration of the mutual promises herein contained and

other good and valuable consideration, agree as follows:

1. Services Offered and Payment. MM provides services to care for the Children, including

infant, toddler, and preschool care during the hours of 7:00 AM – 6:00PM, Monday through

and including Friday (the “Basic Services”). MM also provides optional services, such as

breakfast club, professional photos, and field trips (the “Optional Services”, but collectively

with the Basic Services, the “Services”). MM shall not be required to provide any refunds

whatsoever for Services rendered. All payments shall be made by cash, check, or money

order (no credit card). The payment required for the Services is:

Basic Services rate:

Page 12. 3. 4. Optional Services rates:

Payor: Parents or their insurance, as applicable

Due date: Payments are due weekly, every Monday

Late pickup rates: $1 per minute Children are picked up past 6:00PM

Mindful Moments will provide all child representatives 30 calendar days advaned notice of

any rate changes.

Parents’ Legal Authority. Parents represent and warrant they are responsible for the care,

legal custody, and control of the Children at all times, and no judgment, order, or decree has

been made by any court awarding the custody of the Children to any other person or in any

manner affecting the status or rights of the Parents as the responsible party for the Children.

Immunizations. Parents represent and warrant that Children are current on all

immunizations indicated form IMM-222 Child Care (8/15), as indicated below, and as MM

may required from time to time in writing to Parents.

Legal Forms. Parents were provided with and signed the following forms (collectively, the

“Legal Forms”), the terms of which are incorporated by reference herein, and represent and

warrant that all informaion indicated in such forms is current and accurate:

a. CONSENT FOR EMERGENCY MEDICAL TREATMENT - Child Care Centers

Or Family Child Care Homes; California Department of Social Sevices form LIC

627 (9/08) (CONFIDENTIAL)

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE

CENTERS/FAMILY CHILD CARE HOMES; California Department of Social

Sevices form LIC 700 (8/08)(CONFIDENTIAL)

PHYSICIAN’S REPORT—CHILD CARE CENTERS (CHILD’S PRE-

ADMISSION HEALTH EVALUATION); California Department of Social Sevices

form LIC 701 (8/08) (Confidential)

CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT;

California Department of Social Sevices form LIC 702 (8/08) (CONFIDENTIAL)

PERSONAL RIGHTS – Child Care Centers; California Department of Social

Sevices form LIC 613A (8/08)

CHILD CARE CENTER – NOTIFICATION OF PARENTS’ RIGHTS; California

Department of Social Sevices form LIC 995 (9/08)

PARENTS’ GUIDE TO IMMUNIZATIONS REQUIRED FOR CHILD CARE;

California Department of Public Health, Immunization Branch, form IMM-222

Child Care (8/15)

b. c. d. e. f. g. Page 2Parents shall immediately notify MM, in writing, if any information in the Legal Forms is

inaccurate. Parents shall immediately provide MM with updated forms and/or information.

5. Medical Insurance. Child  is  is not covered by medical insurance.

List insurance carrier and policy number: ______________________________________

6. 7. 8. Consent to Emergency Care / First Aid. Parents expressly permit MM staff and other

emergency care physicians and staff and support personnel to use appropriate first aid and

other procuedures to prevent further injury and/or death to Children in an emergency.

Health Care Policies. If the Children have any of the following conditions or symptoms

(which is determined in MM’s sole and absolute discretion), we will contact you to pick up

your Children from the child care center immediately to prevent contagion of of other

children and staff and esure the well-being of the Children:

a. Fever accompanied by other symptoms

b. Any rash that may be considered contagious

c. Vomitting

d. Diarrhea twice in one day, or uncontrolled diarrhea

e. Uncontrolled coughing

f. Any skin rash, lesion, or wound with bleeding or oozing of clear fluid or pus

g. Conjunctivitis (“pink eye”)

h. Mouth sores with drooling

i. Any condition preventing the Children from participating comfortably in activities

j. Any illness or condition requiring one-to-one care

k. Scabies, head lice, or other infestations

l. Uncontrolled nasal discharge of mucus

m. Any contagious illness or disease reportable to the Department of Public Health

If Children are picked up after the above-mentionted symptoms, the Children must be free

of the above-mentioned symtoms for more than 24 hours to return to the child care center,

repetitive symptoms within several days apart will result in immediate dismissal from the

program, and all antibiotics must be prescribed and taken for 24-hours before returning.

The Children may return to the child care center if the above-mentionted symptoms persist

with a signed note from a physician that is unrelated to the Children by blood or marriage

and who is familiar with the Children’s condition, indicating that the symptoms are not

contagious and do not present a danger to others, including children.

Indemnification. TO THE MAXIMUM EXTENT PERMITTED BY LAW, PARENTS

(AS WELL AS ON BEHALF OF THEIR SUCCESSORS, ASSIGNS, AND LEGAL

REPRESENTATIVES) AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS

MM (INCLUDING, WITHOUT LIMITATION, ITS OFFICERS, AGENTS,

EMPLOYEES, SHAREHOLDERS, BOARD MEMBERS) AGAINST ANY LOSS,

DAMAGE OR EXPENSE INCURRED BY REASON OF ANY CLAIM OR LIABILITY

BASED UPON PERSONAL INJURY (INCLUDING DEATH) OR PROPERTY

DAMAGE ARISING OUT OF ANY ACT OR OMISSION OF OTHER CHILDREN,

THE CHILDREN, OR ANY THIRD PARTIES.

________________ ________________

Page 39. Parent Initials Parent Initials

Limitation of Liability. TO THE MAXIMUM EXTENT PERMITTED BY LAW,

PARENTS, FOR HIM/HERSELF, ON BEHALF OF THE MINOR CHILD(REN)

IDENTIFIED IN THIS AGREEMENT, AND ON BEHALF OF THE PARENTS’

HEIRS, PERSONAL REPRESENTATIVES, SPOUSE, CHILD(REN)’S OTHER

LEGAL REPRESENTATIVES, AND/OR ASSIGNS, DO HEREBY RELEASE, WAIVE,

DISCHARGE, AND COVENANT NOT TO SUE MM AND ITS SHAREHOLDERS,

DIRECTORS, OFFICERS, EMPLOYEES, AGENTS, INDEPENDENT

CONTRACTORS (COLLECTIVELY “MM”), FROM LIABILITY FOR ANY AND ALL

CLAIMS FOR PERSONAL INJURY, ILLNESS, DEATH, PROPERTY DAMAGE, OR

ANY OTHER CLAIM, INCLUDING BUT NOT LIMITED TO COSTS, ATTORNEY

FEES, AND CLAIMS ARISING OUT OF THE ACTIVE AND/OR PASSIVE

NEGLIGENCE OF MM AND/OR ITS AGENTS (THE “CLAIMS”). THIS WAIVER

AND RELEASE IS INTENDED TO BE AS BROADLY INTERPRETED AS

PERMITTED UNDER CALIFORNIA LAW.

________________ ________________

Parent Initials Parent Initials

10. Arbiration. To the maximum extent permitted by law, any dispute arising out of or relating

to this Agreement shall be settled by arbitration in Sacramento County, California, before

one (1) arbitrator who shall be a retired judge admitted to practice law in the State of

California. The arbitration shall be administered by JAMS (or any like organization

successor thereto) pursuant to its Streamlined Arbitration Rules and Procedures. The

arbitrator shall follow any applicable federal law and California state law in rendering an

award. Judgment on the award may be entered in any court having jurisdiction. This clause

shall not preclude any party from seeking provisional remedies in aid of arbitration from a

court of appropriate jurisdiction. The arbitrator’s decision shall be final and binding to the

fullest extent permitted by law and enforceable by any court having jurisdiction thereof.

________________ ________________

Parent Initials Parent Initials

11. Emergency Contact. Parents hereby consent to MM contacting the emergency contact

listed above if the Parents are unavailable and Children require immediate medeical

attention or fail to follow to the rules and regulations of MM.

12. Modification and Termination. MM may amend this Agreement by providing Parents at

least 30 days’ advance written notice. Parents may not amend this Agreement without a

writing signed by both parties. MM may termiante this Agreement, effectdive immediately

upon providing written notice to Parents, for any reason whatsoever. Parents may terminate

this Agreement by providing at least 30 days’ advance written notice to MM.

Notwithstanding the aforementioned, this Agreement shall automatically terminate upon the

death of a Child, and no liability or debt shall accrue after the date of death. Mindful

Moments also may terminate services should payments be late on more than three occasions

in a 12-month period, or in the event of two consecutive missed payments. Mindful

Moments also reserves the right to terminate this agreement with or without cause.

Page 413. Inspection Authority of Department of Social Services. The California Department of

Social Services (the “Department”) has the inspection authority specified in Health and

Safety Code Sections 1596.852, 1596.853 and 1596.8535. The Department has the authority

to interview children or staff without prior consent, and MM must ensure that provisions are

made for private interviews with any children or staff members. The Department has the

authority to inspect, audit, and copy child or child care center records upon demand during

normal business hours. Records may be removed if necessary for copying. Removal of

records shall be subject to the requirements in Sections 101217(c) and 101221(d) of Title II

of the California Code of Regulations. MM must ensure that provisions are made for the

examination of all records relating to the operation of the child care center. The Department

has the authority to observe the physical condition of the child(ren), including conditions

that could indicate abuse, neglect or inappropriate placement.

14. Conset to Surveillance / Photographs. Parents acknowledges that surveillance cameras are

in use for the protection of the facility, its equipment and the children. Parents hereby

consent to the Children being photographed and/or recorded for such purposes. Parents also

consent to the use of the images of the Children on social media pages and other advertising

without the Parents’ or Children’s consent.

15. Miscenllaneous. This Agreement shall inure to the benefit of and be binding on the parties’

respective successors, assigns, heirs, and administrators. If a court, arbitrator, or otherwise

holds any provision of this Agreement to be illegal, unenforceable, or invalid for any

reason, the validity and enforceability of the remaining provisions of this Agreement shall

not be affected. This Agreement, along with the attachments and exhibits referecnes herein,

are the entire agreement among the parties relating to these matters.

IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date

hereinabove set forth.

Date:

_________________________ ______________________________

Signature of Mindful Moments Incorporated

CEO, Ashley Teeney

Date: _________________________ ______________________________

Signature of Parent/Guardian

Date: _________________________ ______________________________

Signature of Parent/Guardian

Page 5Needs and Services Plan

Child’s Name ____________________________________________ Date

_______________

Parent Name

Cell #

____________________________________________

_______________

Daily Routine

Approximate arrival time:

___________________________________

Breakfast

Time

_______________________________________________

_______________

Lunch

Time

__________________________________________________

_______________

Solid Foods? _____________________________________________

Number of Bottles or Cups Daily _______________ as indicated below:

_____ oz of (circle one) Formula / Breast Milk by (circle one) Bottle / Cup at _________ (time)

Sleeping Habits at Night __________________________________________________________

Bed Time at Night ____________ Daily Nap Times _____________________________________

Special Instructions: (Blanket, Baby Doll, etc.) __________________________________________

______________________________________________________________________________

Pacifier: Yes No When

_________________________________________________

Allergies for Diapering: (Desitin, A&D Ointment, Powder, Wipes, etc.) _______________________

______________________________________________________________________________

Please list all other Allergies: (Food, Medications, etc.) ___________________________________

_____________________________________________________________________________

Approximate Daily Departure Time

____________________________________________________

It is very important to us that we provide the best care possible for your child on an ongoing basis. To facilitate

that goal, we will meet informally to discuss aspects of your child’s care as needed, and this form will be

updated quarterly.

Parent’s Signature ____________ ______________ ________________ Date

____ ______ ____

MM Representative ___________ ______________ ________________ Date

____ _____ _____Incidental Medical Services

Plan of Operation

December, 2018

All intermittent health care shall be provided by office staff of Mindful Moments

Incorporated including but not limited to:

• CEO

• Director

• Qualified Teachers

All staff including the above shall be instructed on Inhaled medications and EpiPens at

scheduled First Aid & CPR recertification. Therefore, there shall always be trained staff

on campus. Training of Nebulizers and EpiPens will also be performed by the parent of

the child in need of this type of treatment.

At this time, Mindful Moments Incorporated will not administer Glucose monitoring,

Glucagon, G-tube feeding or ileostomy bags.

All medicines and medical equipment shall be kept in our medicine closet and

inaccessible to children. The notebook with authorizations and medicine logs shall be kept

there, as well as the log in and out form.

All staff has been instructed in Universal precautions and shall be followed in the

administration of all medicines, intermittent healthcare and first aid.

Plan for ensuring proper safety precautions are in place, such as, wearing gloves during

any procedure that involves potential exposure to blood or body fluids, performing hand

hygiene immediately after removal and proper disposal of gloves, and proper disposal of

used instruments in approved containers.

Parents of children taking ongoing medication (daily) will have access to medicine log in

office to follow the dispensing of medication.

Parents of children receiving emergency medication shall be notified by phone call at the

time and given a written report at pickup.

Upon any evacuation, the Director will be responsible for taking medication from

medicine closet and keeping it safe and away from children until evacuation is lifted and

able to return to medicine closet.

Upon completion of medication or expiration of prescription, the director will return

medication to parent and logged out.Administering Inhaled Medication

The licensee or staff person has been provided with written authorization from the

minor’s parent or legal guardian to administer inhaled medication and

authorization to contact the child’s health care provider. The authorization shall

include the telephone number and address of the minor’s parent or legal guardian.

The licensee or staff person complies with specific written instructions from the

child’s physician to which all of the following shall apply:

a. The instructions shall contain all of the following information:

Specific indications for administering the medication pursuant to

the physician’s prescription.

Potential side effects and expected response.

Dose-form and amount to be administered pursuant to the

physician’s prescription.

Action to be taken in the event of side effects or incomplete

treatment response pursuant to the physician's prescription.

Instructions for proper storage of the medication.

The telephone number and address of the child’s physician.

b. The instructions shall be updated as often as needed or at time of new prescription.

The licensee or staff person that administers the inhaled medication to the child shall

record each instance and provide a record to the minor’s parent or legal guardian on a

daily basis.

Nebulizers

Parents must supply Nebulizer, tubing, mouthpieces and all required equipment for use in

treatment. Parents will be responsible for updating or replacing any equipment needed.

The following applies to use of Nebulizers:

The Licensee or staff person has been provided with Nebulizer consent form (lic9166)

written authorization from the minor’s parent or legal guardian to administer inhaled

medication and authorization to contact the child’s health care provider. The

authorization shall include the telephone number and address of the minor’s parent or

legal guardian.

The licensee or staff person complies with specific written instructions from the child’s

parent to which all of the following shall apply:

a. The instructions shall contain all of the following information:1.

Specific indications or schedule for administering the medication

pursuant to the physician’s prescription.

Duration of treatment.

Potential side effects and expected response.3)

Dose-form and amount to be administered pursuant to the

physician’s prescription.

Actions to be taken in the event of side effects or incomplete

treatment response pursuant to the physician’s prescription.

Instructions for proper storage of the medication.

The telephone number and address of the child’s physician.

Instructions on how to clean and store machine.

The licensee or staff person will clean mouth pieces and cups

after each use with mild warm soapy water unless parents

instruct differently, in which parent will have to supply any

special cleaning solutions.

b. The instructions shall be updated as often as needed or at time of new prescription.

The licensee or staff person that administers the inhaled medication to the child shall

record each instance and provide a record to the minor’s parent or legal guardian on a

daily basis.

EpiPen Jr. and EpiPen

The following applies to the use of the EpiPen Jr. or the EpiPen

Use in accordance with the direction and as prescribed by a physician.

Keep ready for use at all times

EpiPens are kept in Medicine Closet in a first aid kit that is out of reach of

children, but accessible to adult staff.

Protect from exposure to light and extreme heat.

Note the expiration date on the unit and replace the unit prior to that date.

Replace any auto-injector if the solution is discolored or contains a precipitate.

(Both the EpiPen Jr. and EpiPen have a see-through window to allow periodic

examination of its contents. The physician may recommend emergency use of an

auto-injector with discolored contents rather than postponing treatment.)

Call 911 and the child’s parent/authorized representative immediately after

administering the EpiPen Jr. or the EpiPen.

Call CCL to communicate the incident.

File a Lic 624 to report incident and keep in child’s file.

Carrying out the Medical Orders of a Child’s Physician/Medication

Parent/Authorized Representative Written Permission

•

The licensee obtains express written consent from the child’s parent/authorized

representative to permit the licensee or designated facility staff to carry out the

physician’s medical orders for a specified child.2.

Physician’s Medical Orders

•

The licensee has obtained from the child’s parent/authorized representative a

copy of written medical orders prescribed by the child’s physician. The medical

orders will include:

A description of the incidental medical service needed, including

identification of any equipment and supplies needed.

A statement by the child’s licensed physician that the medical orders

can be safely performed by a layperson.

Description from the child’s licensed physician of the training required

of the facility licensee or staff to carry out the physician’s medical

orders for a specified child and whether the training can only be

provided by a licensed medical professional.

If the medical orders include the administration of medication by a

designated lay person, the physician’s orders shall include the name of

the medication; the proper dosage; the method of administration; the

time schedules by which the medication is to be administered; and a

description of any potential side effects and the expected protocol,

which may include how long the child may need to be under direct

observation following administration of the medication, whether the

child should rest and when the child may return to normal activities.

Compliance

The licensee will be responsible to ensure the following:

•

The facility has obtained from the parent/authorized representative of the child

the medication, equipment and supplies necessary to carry out the medical orders

of the child’s physician.

•

The person(s) designated to carry out the medical orders prescribed by the child’s

licensed physician will not in any way assume to practice as a professional,

registered, graduate or trained nurse.

•

At least one of the persons designated and trained to carry out the physician’s

medical orders will be onsite or present at all times when the child is in care.

•

The persons designated to carry out the physician’s medical orders have

completed the training indicated by the child’s physician.

•

The person designated to carry out the physician’s medical orders shall comply

with proper safety precautions, such as, wearing gloves during any procedure that

involves potential exposure to blood or body fluids, performing hand hygiene

immediately after removal and disposal of gloves, and disposal of used

instruments in approved containers.

Facility Record Keeping and Notification

•

Maintain a written record of when the medical orders have been performed,

including if medications have been administered and inform the

parent/authorized representative of each occurrence when the medical orders

have been carried out.•

•

The Centrally Stored Medication and Destruction Records form (LIC622) is

available for maintaining records.

Maintain, in the child’s file, a copy of the parent/authorized representative

written authorization.

Maintain, in the child’s file, a copy of written medical orders of the physician.

Prescription Medications Policy

In centers where the licensee choose to handle medications, the licensee is required to

obtain written approval and instructions from a child’s parent/authorized representative

prior to administering any physician-prescribed medication to a child.

In addition to obtaining written approval and instructions from the child’s

parent/authorized representative to administer medication; prescription medication shall

be administered in accordance with the label directions as prescribed by the child’s

physician.Incidental Medical Services

Plan of Operation

December, 2018

Please sign below indicating that you have read, understand and agree to the information in

the preceding five pages.

Student Name:

Parent/Guardian’s Signature: Date:GUIDE TO IMMUNIZ ATIONS

REQUIRED FOR CHILD CARE OR PRESCHOOL

Requirements by Age at Entry and Later (Follow-up is required at every age checkpoint after entry.)

Vaccine 2–3 Months 4–5 Months 6–14 Months 15–17 Months 18 Months–5 Years

Polio (OPV or IPV) 1 dose 2 doses 2 doses 3 doses 3 doses

Diphtheria, Tetanus,

and Pertussis

(DTaP or DTP)

1 dose 2 doses 3 doses 3 doses 4 doses

Measles, Mumps, and

Rubella (MMR)

1 dose

on or after the

1st birthday

1 dose

on or after the 1st birthday

Hib 1 dose 2 doses 2 doses 1 dose

1 dose

on or after the

1st birthday

on or after the 1st birthday (only required for children less than 4 years, 6 months)

Hepatitis B

(Hep B or HBV)

1 dose 2 doses 2 doses 2 doses 3 doses

Varicella (chickenpox,

VAR or VZV)

1 dose

INSTRUCTIONS:

To enter a child care center, day nursery, nursery school, family

day care home, or development center, children must have

received immunizations required by California law.

1. Parents must submit their child’s immunization record as proof.

2. Copy the date of each vaccine onto the California School

Immunization Record (Blue Card, CDPH-286).

3. Determine whether children meet requirements above.

ADMIT A CHILD UNCONDITIONALLY WHO:

• Is 18 months and older and has all immunizations required

for their age, or

• Submits a personal beliefs exemption (PBE) filed at a

prior California child-care facility for missing shots(s) and

immunization records with dates for all required shots not

exempted. The PBE must have been filed before January 1,

2016 and is only valid until entry to transitional kindergarten/

kindergarten. For complete details, see ShotsforSchool.org.

• Submits a licensed physician’s written statement of a

permanent medical exemption for missing shot(s) and

immunization records with dates for all required shots not

exempted.

ADMIT A CHILD CONDITIONALLY IF THE CHILD:

• Is under age 18 months, has received all immunizations required

for age, but will have more required at next age checkpoint.

• Is missing a dose(s) in a series, but the next dose is not due yet

(This means the child has received at least one dose in a series

and the deadline for the next dose has not passed.) The child

may not be admitted if the deadline has passed or the child

has not yet received the 1st dose.

• Has a temporary medical exemption to certain vaccine(s)

and has submitted an immunization record for vaccines not

exempted. The statement must indicate which immunization(s)

must be postponed and when the child can be immunized.

WHEN MISSING DOSES CAN BE GIVEN:

Missing Dose Earliest Date

After Previous Dose

Deadline

After Previous Dose

Polio #2 6 weeks 10 weeks

Polio #3 6 weeks 12 months

DTP/DTaP #2, #3 4 weeks 8 weeks

DTP or DTaP #4 6 months 12 months

Hib #2 2 months 3 months

Hep B #2 1 month 2 months

Hep B #3

(under age 18

months)

2 months after 2nd

dose and at least 4

months after 1st dose

12 months after 2nd

dose and at least 4

months after 1st dose

Hep B #3

(age 18 months

and older)

6 months after 2nd

dose and at least 4

months after 1st dose

2 months after 2nd

dose and at least 4

months after 1st dose

DO NOT ADMIT A CHILD WHO:

Does not fit one of the prior categories. Refer parents to their

physician with a written notice indicating which doses are

needed.

FOLLOW-UP IS REQUIRED AFTER ADMISSION:

• At every age checkpoint above until all doses are received.

• If child was behind schedule and admitted conditionally.

• If child has a temporary medical exemption.

Maintain a list of unimmunized children (exempted or admitted

conditionally), so they can be excluded quickly if an outbreak

occurs. Notify parents of the deadline for missing doses. Review

records every 30 days until all required doses are received.

Questions? Visit ShotsForSchool.org or contact your local health

department (bit.do/immunization).

IMM-230 (1/16) California Department of Public Health • Immunization Branch • ShotsForSchool.orgSTATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CONSENT FOR EMERGENCY MEDICAL TREATMENT-

Child Care Centers Or Family Child Care Homes

AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO

_________________________________________ TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE

FACILITY NAME

PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR

__________________________________________________ . THIS CARE MAY BE GIVEN UNDER

NAME

WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD

NAMED ABOVE.

CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:

DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE

HOME ADDRESS

HOME PHONE

( )

WORK PHONE

( )

LIC 627 (9/08) (CONFIDENTIAL)STATE OF CALIFORNIA

HEALTH AND HUMAN SERVICES AGENCY

IDENTIFICATION AND EMERGENCY INFORMATION

CHILD CARE CENTERS/FAMILY CHILD CARE HOMES

To Be Completed by Parent or Authorized Representative

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING DIVISION

CHILD’S NAME LAST MIDDLE FIRST

ADDRESS NUMBER STREET CITY STATE ZIP

SEX

TELEPHONE

( )

BIRTHDATE

FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST

BUSINESS TELEPHONE

( )

HOME ADDRESS NUMBER STREET CITY STATE ZIP

HOME TELEPHONE

( )

MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST

BUSINESS TELEPHONE

( )

HOME ADDRESS NUMBER STREET CITY STATE ZIP

HOME TELEPHONE

( )

PERSON RESPONSIBLE FOR CHILD LAST NAME MIDDLE FIRST

HOME TELEPHONE

BUSINESS TELEPHONE

( )

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

NAME

ADDRESS TELEPHONE RELATIONSHIP

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER

TELEPHONE

( )

DENTIST ADDRESS MEDICAL PLAN AND NUMBER

TELEPHONE

( )

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

■ ■ CALL EMERGENCY HOSPITAL ■ ■ OTHER EXPLAIN: ____________________________________________________________________________________________________________________

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY

(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)

NAME

RELATIONSHIP

TIME CHILD WILL BE CALLED FOR

SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE

DATE

TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE

DATE OF ADMISSION

DATE LEFT

LIC 700 (8/08)(CONFIDENTIAL)STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING

CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT

CHILD’S NAME SEX FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME

MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME

BIRTH DATE

IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?

DEVELOPMENTAL HISTORY (*For infants and preschool-age children only)

DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

DATE OF LAST PHYSICAL/MEDICAL EXAMINATION

WALKED AT*

MONTHS

BEGAN TALKING AT*

MONTHS

TOILET TRAINING STARTED AT*

MONTHS

PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:

■ ■ Chicken Pox

■ ■ Asthma

■ ■ Rheumatic Fever

■ ■ Hay Fever

DATES

DATES DATES

■ ■ Diabetes

■ ■ Poliomyelitis

■ ■ Epilepsy

■ ■ Ten-Day Measles

(Rubeola)

■ ■ Whooping cough

■ ■ Three-Day Measles

■ ■ Mumps

(Rubella)

SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS

DOES CHILD HAVE FREQUENT COLDS? ■ ■ YES ■ ■ NO

HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF

DAILY ROUTINES (*For infants and preschool-age children only)

WHAT TIME DOES CHILD GET UP?*

WHAT TIME DOES CHILD GO TO BED?* DOES CHILD SLEEP WELL?*

DOES CHILD SLEEP DURING THE DAY?*

WHEN?* HOW LONG?*

DIET PATTERN:

(What does child usually

eat for these meals?)

BREAKFAST

LUNCH

WHAT ARE USUAL EATING HOURS?

BREAKFAST ________________________

LUNCH_____________________________

DINNER

ANY FOOD DISLIKES?

ANY EATING PROBLEMS?

IS CHILD TOILET TRAINED?*

■ ■ YES ■ ■ NO

IF YES, AT WHAT STAGE:* ARE BOWEL MOVEMENTS REGULAR?*

■ ■ YES ■ ■ NO

WHAT IS USUAL TIME?*

WORD USED FOR “BOWEL MOVEMENT”*

WORD USED FOR URINATION*

PARENT’S EVALUATION OF CHILD’S HEALTH

IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?

■ ■ YES ■ ■ NO

IF YES, NAME OF DOCTOR: DOES CHILD TAKE PRESCRIBED MEDICATION(S)?

■ ■ YES ■ ■ NO

IF YES, WHAT KIND AND ANY SIDE EFFECTS:

DOES CHILD USE ANY SPECIAL DEVICE(S):

■ ■ YES ■ ■ NO

IF YES, WHAT KIND: DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?

■ ■ YES ■ ■ NO

IF YES, WHAT KIND:

PARENT’S EVALUATION OF CHILD’S PERSONALITY

HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?

HAS THE CHILD HAD GROUP PLAY EXPERIENCES?

DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)

WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?

REASON FOR REQUESTING DAY CARE PLACEMENT

PARENT’S SIGNATURE DATE

LIC 702 (8/08) (CONFIDENTIAL)STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING DIVISION

CHILD CARE CENTER

NOTIFICATION OF PARENTS’ RIGHTS

PARENTS’ RIGHTS

As a Parent/Authorized Representative, you have the right to:

1. 2. 3. 4. 5. 6. 7. 8. Enter and inspect the child care center without advance notice whenever children are in care.

File a complaint against the licensee with the licensing office and review the licensee’s public file

kept by the licensing office.

Review, at the child care center, reports of licensing visits and substantiated complaints against the

licensee made during the last three years.

Complain to the licensing office and inspect the child care center without discrimination or retaliation

against you or your child.

Request in writing that a parent not be allowed to visit your child or take your child from the child

care center, provided you have shown a certified copy of a court order.

Receive from the licensee the name, address and telephone number of the local licensing office.

Licensing Office Name: _________________________________________________

Licensing Office Address: _________________________________________________

Licensing Office Telephone #: _________________________________________________

Be informed by the licensee, upon request, of the name and type of association to the child care

center for any adult who has been granted a criminal record exemption, and that the name of the

person may also be obtained by contacting the local licensing office.

Receive, from the licensee, the Caregiver Background Check Process form.

NOTE: C ALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO A

PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE

POSES A RISK TO CHILDREN IN CARE.

For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov

LIC 995 (9/08) (Detach Here - Give Upper Portion to Parents)

AC K N OW L E D G E M E N T O F N OT I F I C AT I O N O F (Parent/Authorized Representative Signature Required)

PA R E N T S ’ R I G H T S

I, the parent/authorized representative of ________________________________________________, have

received a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and the

CAREGIVER BACKGROUND CHECK PROCESS form from the licensee.

_____________________________________

Name of Child Care Center

______________________________________________ __________________

Signature (Parent/Authorized Representative) Date

NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given to

parent/authorized representative.

For the Department of Justice “Registered Sex Offender”database go to www.meganslaw.ca.gov

LIC 995 (9/08)STATEOFCALIFORNIA—HEALTHANDHUMANSERVICESAGENCY

CALIFORNIADEPARTMENTOFSOCIALSERVICES

IMPORTANT INFORMATION FOR PARENTS

CAREGIVER BACKGROUND CHECK PROCESS

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

TheCaliforniaDepartmentofSocialServicesworkstoprotectthesafetyofchildreninchildcareby

licensingchildcarecentersandfamilychildcarehomes.Ourhighestpriorityistobesurethatchildren

areinsafeandhealthychildcaresettings.Californialawrequiresabackgroundcheckforanyadult

whoowns,livesin,orworksinalicensedchildcarehomeorcenter.Eachoftheseadultsmustsubmit

fingerprints so that a background check can be done to see if they have any history of crime.If we

find that a person has been convicted of a crime other than a minor traffic violation or a marijuana-

related offense covered by the marijuana reform legislation codified at Health and Safety Code

sections11361.5and11361.7,he/shecannotworkorliveinthelicensedchildcarehomeorcenter

unlessapprovedbytheDepartment.Thisapprovaliscalledanexemption.

Apersonconvictedofacrimesuchasmurder,rape,torture,kidnapping,crimesofsexualviolenceor

molestationagainstchildrencannot by law be given an exemption that would allow them to own,

live in or work in a licensed child care home or center. If the crime was a felony or a serious

misdemeanor, the person must leave the facility while the request is being reviewed.If the crime is

less serious, he/she may be allowed to remain in the licensed child care home or center while the

exemptionrequestisbeingreviewed.

How the Exemption Request is Reviewed

We request information from police departments, the FBI and the courts about the person’s record.

Weconsiderthetypeofcrime,howmanycrimestherewere,howlongagothecrimehappenedand

whetherthepersonhasbeenhonestinwhattheytoldus.

Thepersonwhoneedstheexemptionmustprovideinformationabout:

• Thecrime

• Whattheyhavedonetochangetheirlifeandobeythelaw

• Whethertheyareworking,goingtoschool,orreceivingtraining

• Whethertheyhavesuccessfullycompletedacounselingorrehabilitationprogram

The person also gives us reference letters from people who aren’t related to them who know about

theirhistoryandtheirlifenow.

Welookatallthesethingsverycarefullyinmakingourdecisiononexemptions.Bylawthisinformation

cannotbesharedwiththepublic.

How to Obtain More Information

Asaparentorauthorizedrepresentativeofachildinlicensedchildcare,youhavetherighttoaskthe

licensedchildcarehomeorcenterwhetheranyoneworkingorlivingtherehasanexemption.If you

requestthisinformation,andthereisapersonwithanexemption,thechildcarehomeorcentermust

tell you the person’s name and how he or she is involved with the home or center and give you the

name, address, and telephone number of the local licensing office.You may also get the person’s

name by contacting the local licensing office.You may find the address and phone number on our

website.Thewebsiteaddressishttp://ccld.ca.gov/contact.htm.

LIC995E(10/09)STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PERSONAL RIGHTS

Child Care Centers

Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.

(a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are

not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her

needs.

(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,

threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily

living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to

physical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the

provisions of law regarding complaints including, but not limited to, the address and telephone number of the

complaint receiving unit of the licensing agency and of information regarding confidentiality.

(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor

of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely

voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from

spiritual advisors shall be made by the parent(s), or guardian(s) of the child.

(6) (7) Not to be locked in any room, building, or facility premises by day or night.

Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing

agency.

THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE

LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

NAME

ADDRESS

CITY ZIP CODE AREA CODE/TELEPHONE NUMBER

PLACE IN CHILD'S FILE

DETACH HERE

TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE: Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:

ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the

California Code of Regulations, Title 22, at the time of admission to:

(PRINT THE NAME OF THE FACILITY)

(PRINT THE ADDRESS OF THE FACILITY)

(PRINT THE NAME OF THE CHILD)

(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)

(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE)

LIC 613A (8/08)STATE OF CALIFORNIA

HEALTH AND HUMAN SERVICES AGENCY

PHYSICIAN’S REPORT—CHILD CARE CENTERS

(CHILD’S PRE-ADMISSION HEALTH EVALUATION)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING

PART A – PARENT’S CONSENT (TO BE COMPLETED BY PARENT)

__________________________________________, born ________________________________ is being studied for readiness to enter

(NAME OF CHILD) (BIRTH DATE)

_________________________________________ . This Child Care Center/School provides a program which extends from _____ : ____

(NAME OF CHILD CARE CENTER/SCHOOL)

a.m./p.m. to ______ a.m./p.m. , __________ days a week.

Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this

report to the above-named Child Care Center.

__________________________________________________________ _________________

(SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE)

PART B – PHYSICIAN’S REPORT (TO BE COMPLETED BY PHYSICIAN)

Problems of which you should be aware:

Hearing: Allergies:medicine:

Vision: Insect stings:

Developmental: Food:

Language/Speech: Asthma:

Dental:

Other (Include behavioral concerns):

Comments/Explanations:

MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:

IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)

DATE EACH DOSE WAS GIVEN

VACCINE

1st 2nd 3rd 4th 5th

POLIO (OPV OR IPV)

DTP/DTaP/

DT/Td

(DIPHTHERIA, TETANUS AND

[ACELLULAR] PERTUSSIS OR TETANUS

AND DIPHTHERIA ONLY)

/ / / / / / / / / / / / / / / / / /

/ /

(MEASLES, MUMPS, AND RUBELLA)

MMR

HIB MENINGITIS

(REQUIRED FOR CHILD CARE ONLY)

(HAEMOPHILUS B)

HEPATITIS B

/ / / / / / / /

/ / / /

/ /

VARICELLA

(CHICKENPOX)

/ / / /

SCREENING OF TB RISK FACTORS (listing on reverse side)

■ ■ Risk factors not present; TB skin test not required.

■ ■ Risk factors present; Mantoux TB skin test performed (unless

previous positive skin test documented).

___ Communicable TB disease not present.

I have ■ ■ have not ■ ■ reviewed the above information with the parent/guardian.

Physician:_______________________________________________ Date of Physical Exam: ___________________________________

Address:________________________________________________ Date This Form Completed: _______________________________

Telephone: ______________________________________________ Signature ______________________________________________

■ ■ Physician ■ ■ Physician’s Assistant ■ ■ Nurse Practitioner

LIC 701 (8/08) (Confidential)

PAGE 1 OF 2RISK FACTORS FOR TB IN CHILDREN:

* Have a family member or contacts with a history of confirmed or suspected TB.

* Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America).

* Live in out-of-home placements.

* Have, or are suspected to have, HIV infection.

* Live with an adult with HIV seropositivity.

* Live with an adult who has been incarcerated in the last five years.

* Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents in

nursing homes.

* Have abnormalities on chest X-ray suggestive of TB.

* Have clinical evidence of TB.

Consult with your local health department’s TB control program on any aspects of TB prevention and treatment.

LIC 701 (8/08) (Confidential) PAGE 2 of 2