Application Date.________ Date of Enrollment _

CIDLD'S APPLICATION FOR CIDLD CARETo be completed and placed on file prior to enrollment

Name of Child Birth date(Last) (First) (MI) (Nickname)

Address Zip Code

INFORMATION ABOUT THE FAMILY:Father/Guardian's Name Home PhoneAddress Zip CodeWhere Employed Business Phone

Mother/Guardian's Name Home PhoneAddress Zip CodeWhere Employed Business Phone

Insurance Carrier Policy #

INFORMATION ABOUT YOUR CHILD:Does your child have any known allergies: No __ Yes __ Explain:

Does your child have any chronic illnesses/conditions: No __ Yes __ Explain:

Please give any information concerning your child which will be helpful in his experience in group setting(such as play, eating and sleeping habits, special fears, special1ikes or dislikes).

EMERGENCY CARE INFORMATION:Name of child's doctor Office PhoneAddressName of child's dentist Office PhoneAddressHospital preference Phone

If neither father nor mother (or guardian) can be contacted, call (please list relationship):Name Home Phone Office PhoneName Home Phone Office PhoneIf you cannot call for your child, please give the names of persons to whom the child can bereleased:

I agree that the operator may authorize the physician of his/her choice to provide emergency care in the event thatneither I nor the family physician can be contacted immediately.

(Signature of Parent) (Date)I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of emergency. In anemergency situation, other children in the facility will be supervised by a responsible adult. I will not administer anydrug or any medication without specific instructions from the physician or the child's parent, guardian, or full-timecustodian. Provisions will be made for adequate and appropriate rest and outdoor play.

(Signature of Operator) (Date)

12/99 Children's Medical Report

Name ofChild. Birthdate _

Name of Parent or Guardian _

Address of Parent of Guardian _

A. Medical History (May be completed by parent)

1. Is child allergic to anything? No~ Yes_ If yes, what?

2. Is child currently under a doctor's care? No~ Yes~ If yes, for what reason?

3. Is the child on any continuous medication? No~ Yes~ If yes, what?

4. Any previous hospitalizations or operations? No~ Yes~ If yes, when and for what?

5. Any history of significant previous diseases or recurrent illness? No~ Yes~ ;diabetes No~Yes~; convulsions No~ Yes_; heart trouble No~ Yes~.If others, what/when?

6. Does the child have any physical disabilities: No~ Yes~ If yes, please describe:

Any mental disabilities? No~ Yes~ If yes, please describe:

Signature of Parent or Guardian Date

B. Pbysical Examination: This examination must be completed and signed by a licensed physician, his authorizedagent currently approved by the N. C. Board ofMedicaI Examiners (or a comparable board from borderingstates), a certified nurse practitioner, or a public health nurse meeting DEHNR standards for EPSDT program.Height % Weight %

Head. Eyes Ears Nose Teeth'-----__

Throat Neck Heart Chest Abd/GU----- ~--------- -------Ext Neurological Systemj Skin _

Results of Tuberculin Test, if given: Type date Normal AbnormaI. _Should activities be limited? No~ Yes~ If yes, explain: _Any other recornmendations: _

Date of------------------------------Examination------------------------------- ~-----

Signature of authorized examiner/title Pbone # _

Revised 3-03

Immunization History

Name: DateofBirth: _

Enter the date an immunization was received in the space below or attach a copy of the immunizationrecord. G.S. 130A-155(b) requires all child care facilities to have this information on file.

Enter date of each dose - MonthlDay/Y ear

#5*DTP / DT (circlewhich

#2 #3 #4VACCINE #1

*Polio

**Hib

***Hepatitis B

*MMRcombined doses)

****Chicken Pox

OTHER

OTHER

*Required by State law.**Required by State law for children born on or after 10/1/88.

***Required by State law for children born on or after 7/1/94.****Required by State law for children born on or after 4/1101.

Date Updated:Records Updated by:

Name of Center: -----------------------------------------Discipline and Behavior Management Policy

Date Adopted _

Praise and positive reinforcement are effective methods of the behavior management of children.When children receive positive, non-violent, and understanding interactions from adults and others, theydevelop good self-concepts, problem solving abilities, and self-discipline. Based -on this belief of howchildren learn and develop values, this facility will practice the following discipline and behaviormanagement policy:

We:1. DO praise, reward, and encourage the

children.2. DO reason with and set limits for the

children.3. DO model appropriate behavior for the

children.4. DO modify the cJassroom environment

to attempt to prevent problems beforethey occur.

5. DO listen to the children.6. DO provide alternatives for

inappropriate behavior to the children.7. DO provide the children with natural

and logical consequences of theirbehaviors.8. DO treat the children as peopJe and

respect their needs, desires, andfeelings.

9. DO ignore minor misbehaviors.IO.DO explain things to children on their

levels.I I.DO use short supervised periods of

"time-out"12.00 stay consistent in our behavior

management program.

We:1. DO NOT spank, shake, bite, pinch,

push, pull, slap, or otherwisephysically punish the children.

2. DO NOT make fun of, yell at,threaten, make sarcastic remarksabout, use profanity, or otherwiseverbally abuse the children.

.3. DO NOT shame or punish the childrenwhen bathroom accidents occur.

4. DONOT deny food or rest aspunishment.

5. DO NOT relate discipline to eating,resting, or sleeping.

6. DO NOT leave the children alone,unattended, or without supervision.

7. DO NOT place the children in lockedrooms, closets, or boxes aspunishment.

8. 00 NOT allow discipline of childrenby children.

9. DO NOT criticize, make fun of, orotherwise belittle children's parents,families, or ethnic groups.

I,the undersigned parent or guardian of(child's full name), do hereby state that I have read and received a copy of the facility's Disciplineand Behavior Management Policy and that the facility's director/coordinator (or other designatedstaff member) has discussed the facility's Discipline and Behavior Management Policy with me.

Date of Child's Enrollment: -----------------------------------Signature of Parent or Guardian Date -----------------Distribution: one copy to parenns) signed copy in child's facility record

"Time-Out"

"Time-out" is the removal ofa child for a short period oftime (3 to 5 minutes) from a situation inwhich the child is misbehaving and has not responded to other discipline techniques. The "time-out" space, usually a chair, is located away from classroom activity but within the teacher's sight.During "time-out," the child has a chance to think about the misbehavior which led to hislherremoval from the group. After a brief interval of no more than 5 minutes, the teacher discussesthe incident and appropriate behavior with the child. When the child returns to the group, theincident is over and the child is treated with the same affection and respect shown the otherchildren.

Adapted from original prepared by Elizabeth Wilson, Student, Catawba Valley Technical College

SAMPLEFORM

Infant Feeding Schedule

Name of Child -----'" Date _

Dare of Birth _

General Instructions

1. FoodlBottles Brought Daily: (quantity)

2 Instructions fur Feeding:

A. Bottles (formula, miIk,juice)

B. Food (cereal, baby food, table food)

Parent Signature

Changes in Schedule (Must be recorded as eating habits change)

Date New InstructionsParent or Staff

SignatureIntroduce:Juice

CereaJBaby FoodMilkTable Food

*Must be completed for all children less than 15 months old

The following requirements apply to both centers and homes.TransportationChild care centers or family child care homes providingtransportation for children must meet all motor vehicle laws,including inspection, insurance, license, and restraint requirements.Children may never be left alone in a vehicle and child-staff ratiomust be maintained.

RecordsCenters and homes must keep accurate records such as children'sattendance, immunizations, and emergency phone numbers. Arecord of monthly fire drills practiced with safe evacuation ofchildren must also be maintained. A safe sleep policy must bedeveloped and shared with parents if children younger than 12months are in care.

DisciplineEach program must have a written policy on discipline, mustdiscuss it with parents, and must give parents a copy when thechild is enrolled. Changes in discipline policy must be shared withparents in writing before going into effect. Corporal punishment(spanking, slapping, or other physical discipline) is prohibited inall family child care homes and centers. Religious-sponsoredprograms which notify the Division of Child Development thatcorporal punishment is part of their religious training are exemptfrom that part ofthe law.

Parental RightsParents have the right to enter a family child care home orcenter at any time while their child is present.Parents have the right to see the license displayed in aprominent place.Parents have the right to know how their child will bedisciplined.

The law and rules are developed to establish minimumrequirements. Most parents would like more than minimum care.Child care resource and referral agencies can provide help inchoosing quality care. Check the telephone directory or talk with achild care provider to see if there is a child care resource andreferral agency in your community. For more information visit theResources in Child Care website at: www.ncchildcare.net. Formore information on the law and rules, contact the Division ofChild Development at 919-662-4499 or 1-800-859-0829, or visitour homepage at: httpt//www.ncchildcare.net.

Reviewing Files

A public file is maintained in the Division's mainoffice in Raleigh for every center or family childcare home. These files can be• viewed during work hours;• requested via the Division's web site at

ww,,::.ncchildcare.net; or,• requested by contacting the Division at

1-800-859-0829.

How to Report a ProblemNorth Carolina law requires stafffrom the Division of ChildDevelopment to investigate a licensed family child care home orchild care center when there has been a complaint. Child careproviders who violate the law or rules may be fined up to $1,000and may have their licenses suspended or revoked. If you believethat a child care provider fails to meet the requirements describedin this pamphlet, or if you have questions, please caJl the Divisionof Child Development at 919-662-4499 or 1-800-859-0829.

Child Abuse or NeglectAbuse occurs when a parent or caregiver injures or aJlows anotherto injure a child physically or emotionally. Abuse may also occurwhen a parent or caregiver puts a child at risk of serious injury oraJlows another to put a child at risk of serious injury. Neglectoccurs when a child does not receive proper care, supervision, ordiscipline, or when a child is abandoned. North Carolina lawrequires any person who suspects child abuse or neglect toreport the case to the county department of social services. Inaddition, any person can call the Division of Child Development at9 [9-662-4499 or [-800-859-0829 and make a report of suspectedchild abuse or neglect in a child care operation. Reports can bemade anonymously. A person cannot be held liable for a reportmade in good faith. The operator ofthe program must notifyparents of children currently enroJled in writing of thesubstantiation of any abuse/neglect complaint or the issuance ofany administrative action against the child care facility.

Summary:North Carolina

Child CareLaw and Rules

Division of Child DevelopmentNorth Carolina Department ofHealth and Human Services

319 Chapanoke RoadRaleigh, NC 27603

December 2007

The North Carolina Department of Health and Human Services does not discriminate on thebasis of race, color, national origin, sex, religion, age or disability in

employment or provision of services.

What Is Child Care?The law defines child care as:

three or more unrelated children under 13 years of agereceiving care from a non-relativeon a regular basis, of at least once a weekfor more than four hours per day but less than 24 hours.

It is only when all of these conditions exist that regulation isrequired. The North Carolina Department of Health and HumanServices is responsible for regulating child care. This is donethrough the Division of Child Development. The purpose ofregulation is to protect the well-being of children while they areaway from their parents. The law defining child care is in theNorth Carolina General Statutes, Article 7, Chapter 110.

The North Carolina Child Care Commission is responsible foradopting rules to carry out the law. Some counties and cities inNorth Carolina also have local zoning requirements for child careprograms.

Star Rated LicensesCenters and homes that are meeting the minimum licensingrequirements will receive a one star license. Programs that chooseto voluntarily meet higher standards can apply for a two throughfive star license. The number of stars a program earns is basedupon the education levels their staff meet and the programstandards met by the program.

Family Child Care HomesA family child care home is licensed to care for five or fewerpreschool age children, and an additional three school age children.This includes preschoolers living in the home but the provider'sown school-age children are not counted (Individuals caring forone or two children are exempt from being licensed.) Licenses areissued to family child care home providers who meet the followingrequirements:

Horne providers must be 21 years old with at least a highschool education or its equivalent, and mentally andemotionally capable of caring for children.He or she must undergo a criminal records backgroundcheck initially, and every three years thereafter.

All household members over age 15 who are present in familychild care homes when children are in care must also undergoa criminal records background check. As of December 2008,criminal records rechecks will be done every three years.All family child care home providers must have training inCPR each year and in ITS-SIDS and first aid every three years.They also must complete a minimum number oftraining hoursannually.

All family child care homes must meet basic health and safetystandards. Providers must maintain verification of children'simmunization and health status. They must providedevelopmentally appropriate toys and activities, as well asnutritious meals and snacks for the children in care.

Child Care CentersLicensing as a center is required when six or more children arecared for in a residence or when three or more children are in carein a building other than a residence. Religious-sponsored programsare exempt from some of the regulations described below if theychoose not to be licensed. Programs that operate for less than fourconsecutive months, such as summer camps, are exempt fromlicensing. Child care centers may voluntarily meet higher standardsand receive a license with a higher rating. Centers will be visited atleast annually to make sure they arc following the law and toreceive technical assistance from child care consultants.

Licensed centers must meet requirements in the following areas.

StaffThe administrator of a child care center must be at least 21, andhave at least a North Carolina Early Childhood AdministrationCredential or its equivalent. Lead teachers in a child care centermust be at least 18 and have at least a North Carolina EarlyChildhood Credential or its equivalent. If administrators and leadteachers do not meet this requirement, they must begin credentialcoursework within six months of being hired. Staff younger than18 years of age must work under the direct supervision of staff 21years of age or older. All staff must complete a minimum numberof training hours annually including ITS-SIDS training for anycaregiver that works with infants 12 months of age or younger. Allstaff must also undergo a criminal records background check. Asof December 2008, criminal records rechecks will be done everythree years.Ratios

Ratios are the number of staff required to supervise a certainnumber of children. Group size is the maximum number ofchildren in one group. Ratios and group sizes for licensure areshown below and must be posted in each classroom.

Age Teacher: Child Ratio Maximum GrOUD SizeO~12months 1:5 1012~241Uonths 1:6 122 years old 1:10 203 years old 1:15 254 years old 1:20 25School age 1:25 25

Small centers in a residence that are licensed for six to twelve children may keep up to threeadditional school-age children, depending on the ages of the other children in care. Whenthe group has children ofdifferent ages, stoff-child ratios and group size must be met for theyoungest child in the group.

Space and EquipmentTo meet licensing requirements, there must be at least 25 squarefeet per child indoors and 75 square feet per child outdoors.Outdoor play space must be fenced. Indoor equipment must beclean, safe, well maintained, and developmentally appropriate.Outdoor equipment and furnishings must be child size, sturdy, andfree of hazards that could injure children.

CurriculumThe Division of Child Development does not promote or requireany specific curriculum over another. Child care programs choosethe type of curriculum appropriate for the ages of the childrenenrolled. Activity plans must be available to parents and mustshow a balance of active and quiet activities. Rooms must bearranged to encourage children to explore and use materials ontheir own.

Health and SafetyChildren must be immunized on schedule. Each licensed centermust ensure the health and safety of children by sanitizing areasand equipment used by children. Meals and snacks must benutritious, and children must have portions large enough to satisfytheir hunger. Food must be offered at least once every four hours.Local health, building, and fire inspectors visit licensed programsto make sure standards are met. All children must be allowed toplay outdoors each day (weather permitting) and must have spaceand time provided for rest.

Summary:

North Carolina Child Care Law and Rules

House Bill 1063 -Information for Parents

1 h~'Vebeen grven a Summary ofNor'th Carolina Child Care Law and RUles,dated October 2003, published by the Division of Child Development NorthCarolina Department of Health and Human Services.

I also am aware that a summary of the law is posted at the entrance of HomeTouch Child Care on their bulletin board, in case I need this information int,\\e fut'.l!e.

Dated: ----------------------------------

Home Touch Child CareInfantlToddler Safe Sleep Policy

Date Adopted: Angust 22, 2008

Sudden Infant Death Syndrome (SIDS) is the unexpected death of a seemingly healthy baby for whom nocause of death can be determined based on an autopsy, an investigation of the place where the baby diedand a review of the baby's clinical history.

Child care providers can maintain safer sleep environments for babies that help lower the chances of SIDS.N.C. law requires that child care providers caring for children 12 months of age or younger, implement asafe sleep policy, share this information with parents and participate in training.

In the belief that proactive steps can be taken to lower the risks ofSIDS in child care and that parents andchild care providers can work together to keep babies safer while they sleep, this facility will practice thefollowing state sleep policy:

Safe Sleep Practices

1. All child care staff working in this room, or child care staff who may potentially work in this room, willreceive training on our infant Safe Sleep Policy.

2. Infants will always be placed on their backs to sleep, unless there is a signed sleep position medicalwaiver on file. In that case, a waiver notice will be posted at the infant's crib and the waiver filed in theinfant's file.

3. The American Academy of Pediatrks recommends that babies are placed on their back to sleep,but when babies can easily turn over from the back to the stomach, they can be allowed to adoptwhatever position they prefer for sleep.

4. We will follow this recommendation by the American Academy of Pediatrics. However, child care staffcan further discuss with parents how to address circumstances when the baby turns onto their stomach orside.

5. Visually checking sleeping infants. Sleeping infants will be checked daily, every 60 minutes, byassigned staff. The sleep information will be recorded on a Sleep Chart. The Sleep Chart will be kept onfile for one month after the reporting month. We will be especially alert to monitoring a sleeping infantduring the first weeks the infant is in child care.

We will check to see if the infunt's skin color is normal, watch the rise and fall of the chest to observebreathing and look: to see if the infant is sleeping soundly. We will check the infant for signs ofoverheating including flushed skin color, body temperature by touch and restlessness.

6. Steps will be taken to keep babies from getting too warm or overheating by regulating the roomtemperature, avoiding excess bedding and not over-dressing or over-wrapping the baby.

13

Safe Sleep Environment

7. Room temperature will be kept between 68--75°F and a thermometer kept in the infaot room.

8. Infants' heads will not be covered with blankets or bedding. Infants' cribs will not be covered withblankets or bedding. We may use a sleep sack instead of ablanket

9. No loose bedding, pillows, bumper pads, etc. will be used in cribs. We will tuck any infant blanket insecurely at the foot of the crib.

10 Pacifiers will be allowed in infants' cribs while they sleep.

11. A safety-approved crib with a finn mattress and tight fitting sheet will be used.

12. Only one intant will be in a crib at a time, unless we are evacuating infants in an emergency.

13. No smoking is permitted in the infant room or on the premises.

14. All parents/guardians of infants cared for in the infant room will receive a written copy of ourInfant/Toddler Safe Sleep Policy before enrollment.

15. To promote healthy development, awake infants will be given supervised ''tummy time" for exerciseand for play.

I, the undersigned parent or guardian of -:---:- ---::_(child's full name), do hereby state that I have read and received a copy of the facility's InfantIToddler SafeSleep Policy and that the facility's director/ owner/operator (or other designated staff member) hasdiscussed the facility's InfantIToddler Safe Sleep Policy with me.

Date of Child's Enrollment _

Signature of Parent or Guardian: Date: _

Signature of Child Care Provider. _ Date: _

Distribution: one signed copy to parent(s)/guardian(s); signed copy in child's facility record/

14