FOR OFFICE USE ONLY: TEANECK RECREATION DEPARTMENT ... · After School Application 2015-2016...

TEANECK RECREATION DEPARTMENT

AFTER SCHOOL CHILD CARE PROGRAM

SEPTEMBER 4, 2015 - JUNE 23, 2016

(PLEASE PRINT) APPLICATION FORM

Date ___________

Application fee non-refundable

NAME ___________________________________________________________________________

LAST FIRST MIDDLE INITIAL

NICKNAME ______________________________________________ SEX _____________________

ADDRESS__________________________________________________________________________

TELEPHONE__________________________ BIRTH DATE ______________ AGE _________

FATHER CELL # ______________________ MOTHER CELL #_____________________________

SCHOOL ____________________________ GRADE AS OF SEPTEMBER 2014______________

EMAIL CONTACT __________________________________________________________________

***********************************************************************************

FATHER’S NAME ________________________________________________________________

EMPLOYER NAME & ADDRESS ____________________________________________________

HOURS OF WORK _____________________ BUSINESS PHONE _________________________

***********************************************************************************

MOTHER’S NAME ________________________________________________________________

EMPLOYER NAME & ADDRESS ___________________________________________________

HOURS OF WORK _____________________ BUSINESS PHONE ________________________

FOR OFFICE USE ONLY:

Enrollment

Date: ________________

Proof of Residency _____

Birth Certificate _______

Application Fee _______

Doctor’s Note _________

Proof of Health Ins._____

First Payment _________

APPLICATION FORM PAGE 3 TEANECK RECREATION DEPARTMENT

Child’s Name___________________________

PARENTAL AUTHORIZATION FOR EMERGENCY TREATMENT

LIST ANY MEDICAL RESTRICTIONS AND/OR ALLERGIES: __________________________________

_______________________________________________________________________________________

IN CASE OF EMERGENCY, PLEASE INDICATE NAME AND PHONE NUMBER OF PERSON TO BE

CONTACTED IF PARENT CANNOT BE REACHED:________________________________________

_______________________________________________________________________________________

NAME OF FAMILY PHYSICIAN ___________________________________________________________

ADDRESS OF FAMILY PHYSICIAN __________________________ PHONE NUMBER _________________

PARENT’S SIGNATURE: ______________________________DATE _________________________

*******************************************************************************************

CHILD HEALTH INSURANCE: Company/HMO

Group Number ____________________________Identification # _______________________

I (we) state that we are the parent(s)/guardian(s) having legal custody of the above child and attest that

the information above is correct. I (we) authorized the above child care center director or director’s

designee to obtain emergency treatment for my child. I consent to an x-ray examination, anesthetic,

medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor at a recognized

medical facility under the general or special supervision of licensed physician or surgeon.

The following steps will be followed in an emergency:

1. The parent/guardian will be contacted immediately.

2. The child’s physician will be contacted.

3. We will attempt to contact you through all the emergency persons listed on the child’s application

form.

4. If we cannot contact you or your child’s physician, we will do any or all of the following:

(a) Call for emergency first aid assistance/transportation.

(b) Call another physician.

(c) Have the child transported to an emergency hospital in the company of a staff

PARENT’S SIGNATURE _______________________________DATE ____________________________

*******************************************************************************************

I, the undersigned agree to hold the Township Of Teaneck harmless for any accident, incident,

injury or loss of personal property that may occur as a result of my child’s participation in this

program. With this knowledge, I agree that I will not seek any claims for injury or liability

against the Teaneck Recreation Department and/or the Township.

PARENT’S SIGNATURE _______________________________DATE ____________________________

After School Application 2015-2016 Teaneck Recreation Department

TOWNSHIP OF TEANECK

TEANECK RECREATION DEPARTMENT

AFTER SCHOOL CHILD CARE PROGRAM

This serves as a contract between the Teaneck Recreation Department and parent/guardian of

__________________________________ enrolled in the After School Child Care Program.

Child’s Name

I am in receipt of the program dates, guidelines, parent information, and schedule of payment.

I fully understand that the program will end on Tuesday, June 23, 2015. I further understand

that my child/children are to adhere to the specified guidelines of the program and that if timely

payments including incurred monthly late fees, are not received as indicated on the payment

schedule my child/children’s enrollment will be suspended and/or expelled from this program.

I have been informed that employees are not permitted to accept any compensation nor tokens

of appreciation as this would be a breech in the code of ethics.

______________________________ _______________________________

Parent/Guardian’s Signature Date Lisa Skulnik

Assistant Superintendent of Recreation

Page 6


INFORMATION TO PARENTS

Under provisions of the Manual of Requirements for Child Care Centers (N.J. A.C. 10:22) every

licensed child care center in New Jersey must provide to parents of enrolled children written

information on parent visitation rights, state licensing requirements, child abuse/neglect reporting

requirements and other child care matters. The center may comply with this requirement: 1) by

reproducing and distributing to parents this written statement, prepared by the Bureau of Licensing in

the Division of Youth and Family Services (DYFS); or 2) by incorporating the required information

in it’s own handbooks, brochures or other informational materials. In keeping with this requirement,

the center must secure every parent’s signature attesting to his/her receipt of the information.

***

Our center is required by the State Child Care Center Licensing Law to be licensed by the Bureau of

Licensing of the New Jersey Division of Youth and Family Services. A copy of our current license

must be posted in prominent location at our center. Look for it when you’re in the center.

To be licensed, our center must comply with the Manual of Requirements for Child Care Centers (the

official licensing regulations). The regulations cover such areas as: physical environment/life safety;

the staff qualifications, supervision, and staff/child ratios; program activities and equipment; health,

food and nutrition; rest and sleep requirements; parent/community participation; administrative and

record keeping requirements; and others.

Our center must have on the premises a copy of the Manual of Requirements for Child Care Centers

and make it available to interested parents for review. If you would like to review our copy, just ask

any staff member. Parents may secure a copy of the Manual Requirements for Child Care Centers,

by sending a check or money order for $5.00 made payable to the “Treasurer, State of New Jersey”,

and mailing it to: State of New Jersey, Department of Human Services, Licensing, Publication Fees,

P.O. Box 18500, Newark, New Jersey 07191.

We encourage parents to discuss with us any questions or concerns about the policies and program of

the center or the meaning, application or alleged violations of the Manual of Requirements for Child

Care Centers. We will be happy to arrange a convenient opportunity for you to review and discuss

these matters with us. If you suspect our center may be in violation of licensing standards, you are

entitled to report them to the Bureau of Licensing toll-free at 1-609-292-1021 or 609-292-9220. Of

course, we would appreciate your bringing these concerns to our attention, too.

Our center must have a policy concerning the release of children to parents or people authorized by

the parents to be responsible for the child. Please discuss with us your plans for your child’s

departure from the center.

Our center must have a policy about administering medicine and health care procedures and the

management of communicable diseases. Please talk to us about these policies so we can work

together to keep our children healthy.

Page 3


Information to Parents (page 2)

Our center must have a policy concerning the expulsion of children from enrollment at the center.

Please review this policy so we can work together to keep your child in our center.

Parents are entitled to review the center’s copy of the Bureau of Licensing’s Inspection/Violation Reports

on the center, which are issued after every State licensing inspection of our center. If there is a licensing

complaint investigation, you are also entitled to review the Bureau’s Complaint Investigation Summary

Report, as well as any letters of enforcement of other actions taken against the center during the current

licensing period. Let us know if you wish to review them and we will make them available for your

review.

Our center must cooperate with all DYFS inspection/investigations. DYFS Staff may interview both

staff members and children.

Our center must post its written statement of philosophy on child discipline in a prominent location and

make a copy of it available to parents upon request. We encourage you to review it and to discuss with

us any questions you may have about it.

Our center must post a listing or diagram of those rooms and areas approved by the Bureau for the

children’s use. Please talk to us if you have any questions about the center space.

Our center must offer parents of enrolled children ample opportunity to participate in and observe the

activities of the center. Parents wishing to participate in the activities or operations of the center should

discuss their interest with the center director or their designee who can advise you of what opportunities

are available.

Parents of enrolled children may visit our center at any time without having to secure prior approval from

the director or any staff member. Please feel free to do so when you can. We welcome visits from our

parents.

Our center must inform parents in advance of every field trip, outing or special event away from the

center and must obtain prior written consent from parents before taking a child on each such trip.

Our center is required to comply with the New Jersey Against Discrimination (LAD), P.L. 1945, c. 169

(N.J.S.A. 10:5-1 et seq.), and the Americans with Disabilities Act (ADA), P.L. 101-336 (42 U.S.C.

12101 et. Seq.). Anyone who believes the center is not in compliance with these laws may contact the

Division on Civil Rights in the New Jersey Department of Law and Public Safety for information about

filing an LAD claim at (609) 292-4605 (TTY users may dial 711 to reach the New Jersey Relay Operator

and ask for (609) 292-7701), or may contact the United States Department of Justice for information

about filing an ADA claim at 1-(800)514-0301 (voice) or (800)514-0383 (TTY).

Page 4


Information to Parents (page 3)

Anyone who has reasonable cause to believe that an enrolled child has been or is being subjected to any

form of hitting, corporal punishment, abusive language, ridicule, harsh, humiliating or frightening

treatment or any other kind of child abuse, neglect, or exploitation by any adult, whether working at the

center or not, is required by State law to report the concern immediately to the Division of Youth and

Family Services Office of Child Abuse Control. Toll Free at (800) 792-8610 or to any DYFS District

Office. Such reports may be made anonymously.

Parents may secure information about child abuse and neglect by contacting, Community Education

Office, Division of Youth and Family Services, P.O. Box 717, Trenton, New Jersey 08625-0717.

9/10

Page 5


POLICY ON THE RELEASE OF CHILDREN

A. Each child may be released only to the child’s custodial parent(s) or person(s) authorized by the

custodial parent(s), to take the child from the center and to assume responsibility for the child in an

emergency if the custodial parents cannot be reached.

1. The provision that a child shall not be visited by or released to a non-custodial parent

the custodial parent specifically authorizes the center to allow such visits or

release in writing. This written authorization, including name, address and phone

number shall be maintained in the file.

2. Circumstances may require staff members to seek additional confirmation and/or

verification of consent before releasing a child from the center.

3. Authorized persons must be able to present valid identification prior to release of the

child. Authorized persons must be 16 years or older to assume custody of the child from

the center.

B. Written procedures required to be followed by staff member(s) if the parent(s) or person(s)

authorized by the parent(s), as specified in (A) above, fails to pick-up a child at the

time of the center’s daily closing:

1. The child is supervised at all times;

2. Staff members attempt to contact the parent(s) or person(s) authorized by the parents;

3. An hour or more after closing time, and provided that other arrangements for releasing

the child to his/her parent(s) or authorized person(s) have failed and the staff member(s)

cannot continue to supervise the child at the center, the staff member shall call the Division’s

24 hour Child Abuse Hotline (1-800-792-8610) to seek assistance in caring for the child until

the parent(s) or person(s) authorized by the child’s parent(s) is able to pick-up the child.

C. Written procedures required to be followed by a staff member(s) if the parent(s) or person(s)

authorized by the parent(s), appear to be physically and/or emotionally impaired to the

extent that, in the judgment of the director and/or staff member, the child would be

placed at risk of harm if released to such an individual:

1. The child may not be released to such an impaired individual;

2. Staff members attempt to contact the child’s other parent or an alternate

person(s) authorized by the parent(s); and

3. If the center is unable to make alternative arrangements, as noted

above, a staff member shall call the Division’s 24-hour Child Abuse Hotline

(1-800-792-8610) to seek assistance in caring for the child.

Page 6


POLICY ON THE MANAGEMENT OF COMMUNICABLE DISEASES

If a child exhibits any of the following symptoms, he or she should not attend school. If such symptoms

occur at school, the child will be removed from the classroom, and the parent(s) will be called to take

them home.

Severe pain or discomfort

Acute diarrhea

Episodes of acute vomiting

Elevated oral temperature of 100 degrees Fahrenheit

Sore throat or severe coughing

Yellow eyes or jaundice skin

Red eyes with discharge

Infected untreated skin patches

Difficult or rapid breathing

Skin rashes lasting longer than 24 hours

Swollen joints

Visibly enlarged lymph nodes

Stiff neck

Blood in urine

Once the child is symptom free and or fever free for 24 hours, or has a physician’s note stating that he or

she no longer poses a serious health risk to themselves or others, he or she may return to school.

If a child contracts any of the following diseases, please report it to us immediately. The child may not

return to school without a doctor’s note stating that the child presents no risk to themselves or others.

TABLE OF EXCLUDABLE COMMUNICABLE DISEASES

Respiratory Illnesses Gastro-intestinal Illnesses Contact Illness

Chicken Pox Giardia Lamblia* Impetigo

German Measles* Hepatitis A* Lice

Homophiles Influenza* Salmonella* Scabies

Measles* Shigella*

Strep Throat Escherichia coli*

Meningococcus*

Tuberculosis

Mumps*

Whooping Cough

*Reportable diseases, as specified in N.J.A.C. 10:122-7, 10 (a).

If your child is exposed to any excludable diseases at school you will be notified in writing.

Page 7

Application Form Page 2 Teaneck Recreation Department

Please supply required information

CHILD’S NAME _______________________Age _______ Date of Birth ____________________

ADDRESS_______________________________________________________________________

EMERGENCY CONTACT __________________ Phone # ______________ Cell#_____________

CHILD’S MEDICAL INFORMATION

Is your child under any medical/physical/dietary restrictions? __________Yes ________No

If yes, _____________________________________________________________________________

Is your child taking any medication? ____________Yes ________No

Please name________________________________________________________________________

Has your child been under a doctor’s care or hospitalized within the past three years ?______Yes ______No

If yes ____________________________________________________________________________

Is your child allergic to any medication/food/insect stings? ___________Yes _________No

If yes_______________________________________________________________________________

Any special needs that we should be aware of ? _____________Yes ________No

Please explain ______________________________________________________________________

.

Parent Signature ___________________________________Date :____________________________

Director’s Signature ________________________________Date:_____________________________

I HEREBY GIVE PERMISSION TO HAVE MY CHILD PICKED UP AT THE RECREATION CENTER

BY THE FOLLOWING: (ALL AUTHORIZED PERSONS ARE 16 YEARS OR OLDER)

1. Name ____________________________ Phone __________________ Relationship_______________



PARENT’S SIGNATURE _______________________________DATE ______________________________

MOTHER’S NAME _______________________ FATHER’S NAME _____________________

Home Phone # ____________________________ Home Phone # _________________________

Bus. #___________________________________ Bus. # ________________________________

Cell #___________________________________ Cell # ________________________________

As parent/guardian of the above participating child, I certify that he/she is in good physical health and

has no disability or ailment that would prevent he/she from participating in all of the activities of the

program, except as noted on application.

Parent/Guardian signature ___________________________ Date _____________


Child’s Name______________________________

CHILD’S HEALTH RECORD - School Year 2015-2016

IMMUNIZATIONS AND TESTS

(Exact dates from certificates signed by physician or official agency)

EMERGENCY MEDICAL INFORMATION

Has or is subject to: (check and give details)

_______*Asthma _______ Convulsions ______ Heart Trouble ______ Diabetes _____Fainting Spells

_______ High Blood Pressure _______ Allergy or reaction to medicine, food plant, animals or insect

_______ Any other condition that may require emergency/special care or knowledge

Explain restrictions or limitations:

*If your child has asthma they must have their inhaler with them and know how to use it.

MEDICAL HISTORY

Date of most recent physical exam (Month & Year) _________________________________________________

Any current health problems ___________________________________________________________________

Remarks ___________________________________________________________________________________

Date ______________________ Physician’s Signature ________________________Telephone # ___________

Page 4

Diphteria

Pertussis

Tetanus

Polio Vaccine Measles Rubella Varicella HIB Hepatitis

“B”

Mantoux

TB

Date Date Specify

type

Date Date Date Date Date Date

1st

2nd

3rd Flu Vaccine

1st Booster Date

2nd Booster

3rd Booster

TEANECK BOARD OF EDUCATION

DAYCARE DROP OFF/PICK UP REQUEST FORM (Your child must be eligible for busing to request a daycare stop)

REVISED 1/20/05

Please complete this form if your child will need to be dropped or picked up at a licensed daycare in Teaneck.

The Teaneck Board of Education is responsible for the safe transport of students to and from their home. The district is not

obligated to transport a student to any other location by law. However, as a courtesy, the Teaneck school district will review

and possibly approve a pick-up or drop off request for a licensed daycare center as long as it is located in Teaneck and the bus

route can efficiently and safely accommodate a stop at the licensed facility.

Note: All request for daycare stops for classified students who are picked up and dropped off at home by vans must be

submitted to the special services department in writing (verbal requests are not acceptable per the instructions on the form

below). No one in the school district (to include bus companies) may change a classified student’s drop off or pick up location

except the special services department. All requests will be reviewed by Mr. Anthony Calandrillo, Coordinator of Child Study

Teams, or his designee. If approved, you will be contacted by phone or mail by the special services department. Requests

received after August 1st will be implemented the second week of school if approved.

All requests for children who ride big buses (they walk to corner bus stops) see below.

______________________________________________Cut Here_______________________________________________

REVISED 1/20/05

DAYCARE REQUEST FORM

Please note, all request must be in writing and forwarded to the proper persons as noted below.

_____ My child is classified or is in the process of being classified by the special services department IF THIS

IS CHECKED INDICATING THAT THE CHILD IS CLASSIFIED, THIS FORM MUST BE FORWARDED

TO THE SPECIAL SERVICES DEPARTMENT FOR REVIEW AND POSSIBLE APPROVAL (Fax: (201)833-

5532 or Address: One Merrison Street, Teaneck). If approved, you will be contacted by phone or mail by the special

services department as to the start date.

______ My child rides a big bus (he/she walks to a corner pick up/drop off location) and will attend the Rodda Center

Recreation Program. YOU MUST RETURN THIS FORM TO THE RECREATION DEPARTMENT, 250

COLONIAL COURT, TEANECK (ATTN:LISA SKULNIK) WHEN YOU RE-REGISTER OR REGISTER YOUR

CHILD. The Recreation Center will provide the school district with a list of students who have paid and are

accepted to their program.

______ My child rides a big bus (he/she walks to a corner pick up/drop off location) and will attend another daycare location:

You must return this form to the school secretary for review and approval.

Requests may be submitted for next year as early as June. However, they must be submitted no later than July 30th for review

and possible approval order to be implemented within the first two weeks of school.

School of attendance: ___________________________________________________________________________________

Child Name _______________________________________Grade _________ D.O.B. ______________________________

Parent Name________________________________ Home Address ___________________ Day Phone_________________

Other Location Request AM ______________________________________________(Or NONE)

Name, address, phone number

I have read the transportation procedures to change my child’s pick-up and/or drop off location and understand that in order for

my child to be considered for a daycare stop, she or he must be eligible for busing from our home to the school and I must

complete the name, address, phone number of the daycare (or babysitter), sign and return this form to the proper person for

approval.

Date __________________________________________ Parent Signature ___________________________________

Page 9


POLICY ON AGGRESIVE BEHAVIOR

Dear Parents:

Our mandate is to provide a safe environment in all Recreation Department Youth Division

programs. Therefore, we have set forth the following policy on aggressive behavior. This policy

addresses physical contact between children and/or verbal/physical confrontational behavior of

parents.

Any aggressive behavior such as hitting, kicking, punching, play fighting and/or fighting during the

program that results in physical altercations will not be tolerated. In addition, any physical/verbal

threats of any kind by children or parents will not be tolerated. Any such behavior will be addressed

as follows:

First offense 3 day suspension

Second offense 5 day suspension

Third offense Dismissal from the program

An Aggressive Incident Report Form describing aggressive behavior will be presented to keep you

informed of any incidents of disciplinary action.

If your child is dismissed from the program, no refunds will be permitted.

We would like you to address this with your child/children to make them understand that physical/

verbal aggression is not the solution to any problem and will not be tolerated.

We thank you in advance for your cooperation. If you have any questions you may call me at

201-837-7130 ext. 7010. Please sign below and return this letter to us.

Sincerely,

Lisa Skulnik Assistant Superintendent of Recreation

_____________________________ __________________________

Parent Signature Date

Page 5


PAYMENT SCHEDULE 2015-2016 Date Due Application Fee Amount Period Covered

per Child Sibling

At Registration $15.00 (per child)

At Registration $150.00 $125.00 September 2015

August 1 $150.00 $125.00 June 2016

September 1 $150.00 $125.00 October 2015

October 1 $150.00 $125.00 November 2015

November 1 $150.00 $125.00 December 2015

December 1 $150.00 $125.00 January 2016

January 1 $150.00 $125.00 February 2016

February 1 $150.00 $125.00 March 2016

March 1 $150.00 $125.00 April 2016

April 1 $150.00 $125.00 May 2016

There is a $15.00 non-refundable application fee for all participants for the After School Program.

LATE PICK UP FEE:

There will be a late pickup fee of $30.00 per family after 6:15 p.m. Your child will not be permitted to return to the

program unless this fee is paid.

PLEASE NOTE: Payment is due on the first of the month in the Administrative Office. If payment is not received

by the close of business, 5:00 p.m. on the 5th of the month there will be a $50.00 non-negotiable late charged assessed

per family. Failure to pay by the 12th of the month will result in your child being automatically suspended from the

program until payment is made.

Monthly payments should be made at the Recreation Department’s Administrative Office between the hours of 8:15

a.m. to 5:00 p.m.(Tuesday until 6:30 p.m.), Payments can also be mailed or put in drop box located on the first floor of

the Richard Rodda Community Center.

ALL Checks should be made payable to the “TOWNSHIP OF TEANECK”.

Page 2

TOWNSHIP OF TEANECK RECREATION DEPARTMENT - YOUTH DIVISION

Richard Rodda Community Center

250 Colonial Court

Teaneck, New Jersey 07666

(201) 837-7130 ext. 7010

We welcome you to the After School Child Care Program, held at the Richard Rodda Community Center.

The program operates from school dismissal to 6:00 p.m. Monday thru Friday starting Thursday, September 4, 2015 and

ending Tuesday, June 23, 2016. The program follows the Teaneck Public School Calendar including snow days,

holidays, vacations, as well as all Municipal holidays. Children may participate all five days or any combination of days

during the week; however, no reduction of fee will apply for partial attendance.

The philosophy of the program is to enable the child to foster their self-esteem socially, physically and emotionally

through age appropriate activities. Daily activities include time for homework (with staff assistance), cooking, “Get Fit,

Get Healthy” activities, Drop Everything and Read Fridays, spelling bees, sports, free play, arts and crafts, and special

events (science fair, talent show, mini Olympics). The program offers children a game room featuring ping pong,

foosball, pool, and an assortment of board games. We believe that by incorporating all of the mentioned, we encourage

independent thinking, and cultivate individual talents. Daily snacks are provided, as well as weekly Thursday Pizza, and

end of the month Pasta and Salad Thursday.

No child will be permitted to enroll in the program if over age thirteen after the date of September 30, 2015.

There is an initial application fee for each child of $15.00. These application fees are due at the time of registration and

are non-refundable.

Registration will begin Wednesday, May 28 by either Mail In or Drop Box located on the first floor of the Richard

Rodda Community Center. Registration for our program is open to residents of Teaneck only.

For your convenience, a check list with all necessary documents to be completed and returned is provided:

______ Completed Application

______ Day Care Drop Off/Pick Up Request Form

______ Proof of Residency

______ $15.00 application fee payable to “Township of Teaneck”

______ Signed “Aggressive Behavior Policy” Form

______ Signed “Expulsion Policy” Form

______ Completed Child Health Record (Immunization History from Doctor)

If you have any questions or need further information please call 201-837-7130, ext 7010.

FOR OFFICE USE ONLY: TEANECK RECREATION DEPARTMENT ... · After School Application 2015-2016...

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