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2019 Online Enrollment Form

Step 1 of 6

CIVIL RIGHTS COMPLIANCE PARENT AWARENESS FORM
In accordance with applicable Federal and State Civil Rights Laws and Regulations, you and your children, as clients of this facility have the right:

To be provided services at this facility and to be referred for services at other facilities without regard to race, color, religious creed, handicap, ancestry, national origin, age or sex.

If you feel you have been discriminated against on the basis of your race, color, religious creed, handicap, ancestry, national origin, age or sex, you may file discrimination complaints with any of the following agencies:
Apple Pie Christian Academy
3 S State Road
Upper Darby, PA 19082
Commonwealth of Pennsylvania
Department of Human Services
Room 225, Health & Welfare Building
PO Box 2675
Harrisburg, PA 17105

U. S. Department of Health and Human Services
Office for Civil Rights
Suite 372, Public Ledger Bldg.
150 South Independence Mall West
Philadelphia, PA 19106-9111
PA Human Relations Commission
Philadelphia Regional Office
110 N. 8th Street
Suite 501
Philadelphia, PA 19107

Commonwealth of Pennsylvania
DPW Bureau of Equal Opportunity
Southeast Regional Office
801 Market Street, Suite 5034
Philadelphia, PA 19107
By signing below I indicate I was made aware of the location of the above information in the Parent Handbook I received when I enrolled my child(ren) in the center.
Parent/ Guardian Signature*
Date*
MM slash DD slash YYYY
PHOTO CONSENT FORM
We at Apple Pie Christian Academy would like your signed permission to take pictures of you and your child(ren) for our computer data base, for field trips or any other special occasion that we would like to capture you or them on film or still shot photography. This allows us to maintain a computer record of your picture, your child’s picture and helps us to post pictures of the children and parents as they are enjoying a special activity.

This document DOES NOT allow Apple Pie Day Care to use your photo for marketing or advertising on a brochure or an internet web site. We WILL NOT use the picture for marketing purposes.

By signing below I authorize Apple Pie Christian Academy to take pictures or video of me and my child(ren) and use them within the child care center only.

Jim Mattera, Owner
Apple Pie Christian Academy
Parent/ Guardian Signature*
Date*
MM slash DD slash YYYY
AGREEMENT
55 PA CODE CHAPTERS 3270.123 &.181(C); 3280.123 &.181(c); 3290.123 &.181(c)
NAME OF CHILD*
FEE AMOUNT $*
PER-DAY-WEEK*
DAY PAYMENT TO BE MADE*
Services to be provided as part of the day care fee (examples; transportation, care, meals, etcJ
CHILD'S ARRIVAL TIME*
CHILD'S DEPARTURE TIME*
LATE FEE $*
PER MIN-HR*
PERSON(S) DESIGNATED BY PARENT TO WHOM CHILD MAY BE RELEASED*
Extra services to be provided at an additional fee if applicable
I, the parent/guardian*
- received complete written program information at the time of enrollment (§ 3270.121, 3280.121, 3290.121
- agree to update the emergency contact/parental co sent form information whenever changes occur or every 6 months at a minumum. (9 3270.124, 3280.124, 3290.124)
Signature - Operator*
Date*
MM slash DD slash YYYY
Parent/ Guardian Signature*
Date*
MM slash DD slash YYYY
Date of Child's Admission*
MM slash DD slash YYYY
Date of Withdrawal*
MM slash DD slash YYYY
Periodic Review
Parent/ Guardian Signature*
Date*
MM slash DD slash YYYY

CHILD HEALTH REPORT
(55 PA CODE §§3270.131, 3280.131 AND 3290.131)
CHILD’S NAME*
DATE OF BIRTH*
MM slash DD slash YYYY
HOME PHONE
FACILITY PHONE
COUNTY
PARENT/GUARDIAN*
ADDRESS*
WORK PHONE
*
- I authorize the child care staff and my child’s health professional to communicate directly if needed to clarify information on this form about my child.
PARENT’S SIGNATURE*
DO NOT OMIT ANY INFORMATION

This form may be updated by a health professional. Initial and date any new data. The child care facility needs a copy of the form.
HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND DIAGNOSIS/TREATMENT IN EMERGENCY (DESCRIBE, IF ANY):
DESCRIBE ALL MEDICATION AND ANY SPECIAL DIET THE CHILD RECEIVES AND THE REASON FOR MEDICATION AND SPECIAL DIET. ALL MEDICATIONS A CHILD RECEIVES SHOULD BE DOCUMENTED IN THE EVENT THE CHILD REQUIRES EMERGENCY MEDICAL CARE. ATTACH ADDITIONAL SHEETS IF NECESSARY.
CHILD’S ALLERGIES (DESCRIBE, IF ANY)
LIST ANY HEALTH PROBLEMS OR SPECIAL NEEDS AND RECOMMENDED TREATMENT/SERVICES. ATTACH ADDITIONAL SHEETS IF NECESSARY TO DESCRIBE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHILD, INCLUDING INDICATION OF SPECIAL TRAINING REQUIRED FOR STAFF, EQUIPMENT AND PROVISION FOR EMERGENCIES.
IN YOUR ASSESSMENT, IS THE CHILD ABLE TO PARTICIPATE IN CHILD CARE AND DOES THE CHILD APPEAR TO BE FREE FROM CONTAGIOUS OR COMMUNICABLE DISEASES?
- Yes
- No
IF NO, PLEASE EXPLAIN YOUR ANSWER:
HAS THE CHILD RECEIVED ALL AGE APPROPRIATE SCREENINGS LISTED IN THE ROUTINE PREVENTIVE HEALTH CARE SERVICES CURRENTLY RECOMMENDED BY THE AMERICAN ACADEMY OF PEDIATRICS? (SEE SCHEDULE AT WWW.AAP.ORG)
- Yes
- No
NOTE BELOW IF THE RESULTS OF VISION, HEARING OR LEAD SCREENINGS WERE ABNORMAL. IF THE SCREENING WAS ABNORMAL, PROVIDE THE DATE THE SCREENING WAS COMPLETED AND INFORMATION ABOUT REFERRALS, IMPLICATIONS OR ACTIONS RECOMMENDED FOR THE CHILD CARE FACILITY.
VISION (subjective until age 3)
HEARING (subjective until age 4)
LEAD
RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD’S IMMUNIZATION RECORD
HEP-B
Date Date Date Date Date COMMENTS
ROTAVIRUS
Date Date Date Date Date COMMENTS
DTAP/DTP/TD
Date Date Date Date Date COMMENTS
HIB
Date Date Date Date Date COMMENTS
PNEUMOCOCCAL
Date Date Date Date Date COMMENTS
POLIO
Date Date Date Date Date COMMENTS
INFLUENZA
Date Date Date Date Date COMMENTS
MMR
Date Date Date Date Date COMMENTS
VARICELLA
Date Date Date Date Date COMMENTS
HEP-A
Date Date Date Date Date COMMENTS
MENINGOCOCCAL
Date Date Date Date Date COMMENTS
OTHER
Date Date Date Date Date COMMENTS
MEDICAL CARE PROVIDER:
ADDRESS:
SIGNATURE OF PHYSICIAN, CRNP OR PHYSICIAN’S ASSISTANT
TITLE:
LICENSE NUMBER:
DATE FORM SIGNED:
MM slash DD slash YYYY

Name (List only household members with income) Ex. Jane Smith	Earnings from work before deductions ex. $200/weekly	Welfare, child support, alimony ex. $150/twice a month	Pensions, retirement, Social Security, SSI, VA benefits ex. $100/monthly	All Other Income

Enroll Online

Enroll With Us Today!

2019 Online Enrollment Form

Step 1 of 6

REGISTRATION FORM

CIVIL RIGHTS COMPLIANCE PARENT AWARENESS FORM

PHOTO CONSENT FORM

AGREEMENT

EMERGENCY CONTACT / PARENTAL CONSENT FORM

CHILD HEALTH REPORT

Child and Adult Care Food Program  Child Enrollment Form

Child and Adult Care Food Program  Child Care Center Meal Benefit Income Eligibility Form

Follow Us on Social Media!

Apple Pie State Road

Apple Pie Long Lane

Apple Pie Chester

Name	TELEPHONE NUMBER WHEN CHILD IS IN CARE

Name	ADDRESS	TELEPHONE NUMBER WHEN CHILD IS IN CARE

Names of Enrolled Child(ren) (First, Middle Initial, Last)	Foster child? Yes/No (the legal responsibility of a welfare agency or court) * If all children Listed below are foster children, skip to Part 5 to sign this form	NO income? Yes/ No

Names of all Household Members (First, Middle Initial, Last)	Foster child? Yes/No (the legal responsibility of a welfare agency or court) * If all children Listed below are foster children, skip to Part 5 to sign this form	NO income? Yes/ No

Enroll Online

Enroll With Us Today!

2019 Online Enrollment Form

Step 1 of 6

REGISTRATION FORM

CIVIL RIGHTS COMPLIANCE PARENT AWARENESS FORM

PHOTO CONSENT FORM

AGREEMENT

EMERGENCY CONTACT / PARENTAL CONSENT FORM

CHILD HEALTH REPORT

Child and Adult Care Food Program Child Enrollment Form

Child and Adult Care Food Program Child Care Center Meal Benefit Income Eligibility Form

Follow Us on Social Media!

Apple Pie State Road

Apple Pie Long Lane

Apple Pie Chester

Child and Adult Care Food Program  Child Enrollment Form

Child and Adult Care Food Program  Child Care Center Meal Benefit Income Eligibility Form