Enroll Online Enroll With Us Today! Just fill out the below form to start enrollment with us! 2019 Online Enrollment Form Step 1 of 6 16% REGISTRATION FORMHow many children are you enrolling?*123Child's Name*Date of Birth* Date Format: MM slash DD slash YYYY Sex*BoyGirlChild's NameDate of Birth Date Format: MM slash DD slash YYYY SexBoyGirlChild's NameDate of Birth Date Format: MM slash DD slash YYYY SexBoyGirlParent/Guardian Registering Child*Address*State*Zip*Home PhoneWork PhoneCell PhoneE-Mail Address* Work*Full TimePart TimeIf Part Time Days (check all that apply): Monday Tuesday Wednesday Thursday Friday You have received a package that contains all of the Title 55 Pennsylvania Code references you will need to make an educated decision about your child’s child care facility. Please be sure to read all of the material enclosed before placing your child into Apple Pie Christian Academy. WE RECOGNIZE IT IS CONFIDENTIAL BUT IF YOUR CHILD HAS AN IEP OR IFSP PLEASE SHARE IT WITH THE CENTER DIRECTOR AT THE TIME OF ENROLLMENT.Parent/ Guardian Signature*Date* Date Format: MM slash DD slash YYYY CIVIL RIGHTS COMPLIANCE PARENT AWARENESS FORMIn 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* Date Format: MM slash DD slash YYYY PHOTO CONSENT FORMWe 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 AcademyParent/ Guardian Signature*Date* Date Format: MM slash DD slash YYYY AGREEMENT55 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, etcJCHILD'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 applicableI, 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* Date Format: MM slash DD slash YYYY Parent/ Guardian Signature*Date* Date Format: MM slash DD slash YYYY Date of Child's Admission* Date Format: MM slash DD slash YYYY Date of Withdrawal* Date Format: MM slash DD slash YYYY Periodic ReviewParent/ Guardian Signature*Date* Date Format: MM slash DD slash YYYY EMERGENCY CONTACT / PARENTAL CONSENT FORM55 PA CODE CHAPTERS 3270.124(a)(b), 3270.181 & 182: 3280.124 (a)(b), 3280.181 & .182; 3290.124 (a)(b), 3290.181 & .182 CHILD'S NAME*BIRTHDATE* Date Format: MM slash DD slash YYYY ADDRESS*MOTHER'S NAME/LEGAL GUARDIAN*HOME TELEPHONE NUMBER*ADDRESS*BUSINESS NAME*BUSINESS TELEPHONE NUMBER*BUSINESS ADDRESS*FATHER'S NAME/LEGAL GUARDIAN*ADDRESS*BUSINESS NAME*BUSINESS TELEPHONE NUMBER*BUSINESS ADDRESS*EMERGENCY CONTACT PERSON(S)NameTELEPHONE NUMBER WHEN CHILD IS IN CARE PERSON(S) TO WHOM CHILD MAY BE RELEASEDNameADDRESSTELEPHONE NUMBER WHEN CHILD IS IN CARE NAME OF CHILD'S PHYSICIAN/MEDICAL CARE PROVIDERTELEPHONE NUMBERADDRESSSPECIAL DISABILITIES (IF ANY)ALLERGIES (INCLUDING MEDICATION REACTION)MEDICAL or DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATIONMEDICATION, SPECIAL CONDITIONSADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILDHEALTH INSURANCE COVERAGE FOR CHILD or MEDICAL ASSISTANCE BENEFITSPOLICY NUMBER (REQUIRED)PARENT'S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT OBTAINING EMERGENCY MEDICAL CARE*WALKS AND TRIPS*TRANSPORTATION BY THE FACILITY*ADMIN. OF MINOR FIRST - AID PROCEDURES*SWIMMING*WADING*SIGNATURE OF PARENT or GUARDIAN*Date* Date Format: MM slash DD slash YYYY SIGNATURE OF PARENT or GUARDIAN*Date* Date Format: MM slash DD slash YYYY CHILD HEALTH REPORT(55 PA CODE §§3270.131, 3280.131 AND 3290.131) CHILD’S NAME*DATE OF BIRTH* Date Format: MM slash DD slash YYYY HOME PHONEFACILITY PHONECOUNTYPARENT/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)LEADRECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD’S IMMUNIZATION RECORD HEP-BDateDateDateDateDateCOMMENTSROTAVIRUSDateDateDateDateDateCOMMENTSDTAP/DTP/TDDateDateDateDateDateCOMMENTSHIBDateDateDateDateDateCOMMENTSPNEUMOCOCCALDateDateDateDateDateCOMMENTSPOLIODateDateDateDateDateCOMMENTSINFLUENZADateDateDateDateDateCOMMENTSMMRDateDateDateDateDateCOMMENTSVARICELLADateDateDateDateDateCOMMENTSHEP-ADateDateDateDateDateCOMMENTSMENINGOCOCCALDateDateDateDateDateCOMMENTSOTHERDateDateDateDateDateCOMMENTSMEDICAL CARE PROVIDER:ADDRESS:SIGNATURE OF PHYSICIAN, CRNP OR PHYSICIAN’S ASSISTANTTITLE:LICENSE NUMBER:DATE FORM SIGNED: Date Format: MM slash DD slash YYYY Child and Adult Care Food Program Child Enrollment FormEnrollment Date* Date Format: MM slash DD slash YYYY Child*Child Address*Birth Date* Date Format: MM slash DD slash YYYY Parent/Guardian*Address*Telephone (home)*WorkSponsoring OrganizationAddressCenter/HomeAddressNormal Hours of Care (write in times}*Monday (Start-End)Tuesday (Start-End)Wednesday (Start-End)Thursday (Start-End)Friday (Start-End)Saturday (Start-End)Sunday (Start-End)* If more than 8 hours of care per day, please add an explanation.Daily Expected Meal Service Participation (please check box) Breakfast AM Snack Lunch PM Snack Supper Eve Snack Is this child of school age? Yes No If yes, will additional meals be provided when school is not in session? Yes No If yes, please specify the meal: Breakfast Lunch Snack Supper Parental Contacts:This child care facility participates in the Child and Adult Care Food Program. In order to receive federal funds, representatives of the sponsoring organization or the State Agency may contact you to verify your child's participation. Please indicate what time and method of contact you prefer: Day Evening Letter Telephone (Home) Telephone (Work) Parent/Guardian Signature*Date* Date Format: MM slash DD slash YYYY Center Administrator/Home ProviderDate Date Format: MM slash DD slash YYYY "In accordance with Federal law and U. S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. (Not all prohibited bases apply to all progrcuns). " " To file a complaint of discrimination, write USDA, -Director, Office of Civil Rights,-Room 326-K Whitten Building, =1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer." For Sponsor Use OnlyChild Withdrew on Date Format: MM slash DD slash YYYY Child and Adult Care Food Program Child Care Center Meal Benefit Income Eligibility FormPart 1. All Household MembersNames 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 formNO 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 formNO income? Yes/ No Part 2. Benefits: If any member of your household received [State SNAP], [FDPIR], or [State TANF cash assistance], provide the name and case number for the person who receives benefits. If no one receives these benefits, skip to part 3.NAMECASE NUMBERPart 3. If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box and call [Your center director, Homeless Liaison, Migrant Coordinator at Phone it] Homeless Migrant Runaway Total Household Gross Income --- You must tell us how much and how oftenName (List only household members with income) Ex. Jane SmithEarnings from work before deductions ex. $200/weeklyWelfare, child support, alimony ex. $150/twice a monthPensions, retirement, Social Security, SSI, VA benefits ex. $100/monthlyAll Other Income Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign) An adult household member must sign this form_ If Part 3 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the "I do not have a Social Security Number" box. (See Privacy Act Statement on the back of this page.) I certify that all information on this form is true and that all income is reported. I understand that the center or day care home will get Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted_ Signature*Print Name*Date* Date Format: MM slash DD slash YYYY Address*City*State*Zip Code*Phone Number*Last four digits of Social Security Number I do not have a Social Security Number CAPTCHANumberNameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.