Child Development Programs

Child Development Programs
Family Child Care Home Educational Network, Full-Day State Preschool,
General Center-Based Care, Part-Day State Preschool
CONTRACT AGREEMENT
1. I declare under penalty of perjury that the information contained in my “Confidential Application for Child
Development Services and Certification of Eligibility” is true and correct to the best of my knowledge.
2. I will notify the agency immediately if there is any change in my income, family size, residence,
employment, or reason for needing child development services.
3. I understand that the information about my eligibility may be reviewed by representatives of the state of
California, the federal government, independent auditors, or others as necessary for the administration of the
program.
4.
I understand that if the agency denies this application for services, I have the right to appeal.
5. I understand that I must renew my eligibility at least once a year (at least once every 6 months for protective
services children, 3 months for children referred by an agency other than County Services). I further
understand that if I do not renew my eligibility, I will no longer be eligible for subsidized child-care services
for my child.
6. I understand that I will receive a notice of approval or disapproval of my application within 30 days from
the date I sign this form.
7. I understand that this certification is not complete until all documentation is submitted and the “Confidential
Application for Child Development Services and Certification of Eligibility” form has been reviewed,
signed, and dated by an agency representative and signed and dated by me.
8. I understand that my family may be terminated from the program if I fail to comply with any part of this
contract.
9. I understand that Plaza Community Center, Inc., d/b/a Plaza Community Services, may make changes to this
contract agreement as needed to conform to the laws of the state. I agree to abide by any changes to the
contract after being given proper notice of at least 14 days of the change.
_______________________________________
Parent/Guardian Signature
______________________
Date
_______________________________________
Authorized Agency Representative
______________________
Date
09/29/13
California Department of Education
Child Development Division
(To be completed by parent or guardian and updated
at recertification and as changes occur.)
Emergency and Identification Information
I.
FAMILY INFORMATION
CHILD’S NAME
GENDER
BIRTHDATE
ADDRESS
MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME
EMAIL ADDRESS
RESPONSIBLE
FOR CHILD
CELL PHONE
(
HOME ADDRESS
)
-
HOME PHONE
(
WORK ADDRESS
PERSON TO ASK FOR
)
(
FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME
EMAIL ADDRESS
RESPONSIBLE
FOR CHILD
-
WORK PHONE
)
-
CELL PHONE
(
HOME ADDRESS
)
-
HOME PHONE
(
WORK ADDRESS
PERSON TO ASK FOR
)
-
WORK PHONE
(
)
-
II. NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY
(THIS CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR GUARDIAN.)
NAME
ADDRESS
CITY
ZIP
PHONE
(
)
-
(
)
-
(
)
-
RELATIONSHIP
III. ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY TO TAKE CHILD FROM THE FACILITY
NAME
ADDRESS
CITY
ZIP
PHONE
RELATIONSHIP
(
)
-
(
)
-
(
)
-
IV. PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY
PHYSICIAN
ADDRESS
CITY
ZIP
PHONE
(
MEDI-CAL OR MEDICAL PLAN NAME:
DENTIST
)
-
)
-
MEDI-CAL NUMBER OR MEDICAL PLAN NUMBER
ADDRESS
CITY
ZIP
PHONE
(
DENTAL PLAN:
DENTAL PLAN NUMBER
IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?
CALL 911
OTHER EXPLAIN:
V. ALLERGIES OR OTHER MEDICAL LIMITATIONS
VI. PERMISSION FOR MEDICAL TREATMENT
Administrative procedures vary among medical personnel and medical facilities with regard to provision of medical care for a child in the
absence of the parent. The exact procedure required by the physician or hospital to be used in emergencies should be verified in advance.
In case of accident or an emergency, I authorize a staff member of the child development agency to take my child to the above named physician
or to the nearest emergency hospital for such emergency treatment and measures as are deemed necessary for the safety and protection of the
child, at my expense.
SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE
TIME CHILD WILL BE CALLED FOR
DATE
TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR OR AUTHORIZED REPRESENTATIVE
DATE OF ADMISSION
For CD-9607 & LIC 700 (Rev. 07/11)
DATE LEFT
EARLY CHILDHOOD SERVICES
ACKNOWLEDGEMENT OF RECEIPT OF FAMILY HANDBOOK
By signing below, I acknowledge that I,
, parent/guardian of
, have received a copy of the Family Handbook from the Plaza Early
Childhood Services checked below:
Plaza Child
Development Center
648 S Indiana St
Los Angeles, CA 90023
Plaza Child
Development Center
2737A W Sunset Blvd
Los Angeles CA 90026
Plaza-La Roca Verde
Child Dev. Center
702 S Gerhart Ave
Los Angeles CA 90022
Los Angeles CA 90021
Plaza CS Child
Development Center
4198 Union Pacific Av
Los Angeles CA 90023
Plaza-The Salvation
Army Child Care Ctr.
836 Stanford Ave
Plaza FCCH EHS-CCP
4100 City Terrace Dr
Los Angeles CA 90063
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
Plaza Family Child
Care Home Educ. Net.
1605 E 1st St
Los Angeles CA 90033
Plaza Early Childhood Services, a subsidiary of Plaza Community Center, Inc., dba Plaza Community Services
reserves the right to modify the Family Handbook at any time because of needs or changes of the program or changes
in California
(rev. 06/29/15)
PLAZA EARLY CHILDHOOD SERVICES
PARENT’S NEEDS ASSESSEMENT
(VALORACION DE NECESIDADES DE PADRES)
DATE: _____/_____/_____
PARENT’S NAME: ______________________________
(NOMBRE DE PADRES)
The purpose of this Confidential Form is to assess the family and to provide assistance, services or referrals.
Please check (  ) off any items that pertain to you.
El proposito de esta Forma Confidencial es para valorar la familia y proporcionar asistencia, servicios o
referencias. Por favor marque (  ) cualquier detalle que le pertenesca a usted.
PHYSICAL NEEDS/ NECESIDADES FISICAS:
01. ___Housing/Vivienda
02. ___Women’s Battered Shelter/Refugio para mujeres maltratadas.
03. ___Home Safety Repair/Reparacion de Seguridad para el Hogar
04. ___Furniture/Muebles.
05. ___Landlord/Tenant Problems/Propretario/Rentero problemas.
06. ___Emergency Food/Comida de Emergencia.
07. ___Food Stamps/Estampillas de Comida.
08. ___Infant Feeding/Alimento Infantil.
09. ___Adult Clothing/Ropa para Adulto.
10. ___Child Clothing/Ropa para bebé.
11. ___Hygiene/Higiene
12. ___Transportation/Transportacion
13. ___Alcohol Abuse/Abuso de Alcohol.
14. ___Drug Abuse/ Abuso de Drogas.
15. ___Medical Needs/Necesidades Medicas.
16. ___Mental/Emotional Needs/Necesidades Mental/Emocionales.
17. ___Dental Needs/Necesidades Medicas..
18. ___Medi-Cal/Medi-Cal.
19. ___Infant Care/Cuidado de Niños.
20. ___Child Care/Cuidado de Niños.
21. ___After School Care/Cuidado despues de la Escuela.
22. ___Teen Pregnancy/Embaraso de Adolesentes.
23. ___Public Assistance (AFDC, SSI, SSP)/Asistensia Publica (AFDC, SSI, SSP).
24. ___Financing Budgeting/Financiar Presupuestos.
25. ___Job (Employment Search)/Trabajo(Busqueda de Empleo).
26. ___Job Training/Entrenamiento de Trabajo.
27. ___Unemployment Benefits/Benificios de Desempleo.
28. ___Domestic Violence/Violencia Domestica.
29. ___Immigration Information/Informacion de Immigracion.
30. ___Employer Harassment/Presecucion de Patron.
31. ___Sexual Harassment/Presecucion Sexual.
32. ___Other (Please make list)/Otros (Por favor haga una lista).
SOCIAL/EMOTIONAL NEEDS/NECESIDADES SOCIAL/EMOCIONAL:
01. ___Marriage Counseling/Consejos Matrimoniales.
02. ___Divorce, Separation/Divorcio. Separacion.
03. ___Restraining Orders/Orden de Readaptacion
04.___Child Support, Custody/Sostenimiento, Custodia de Niños.
05. ___Psychological Counseling/Ayuda Psicologica.
06. ___Child Counseling/Consejeria de Niños.
07. ___Teen Counseling/Consejeria de Adolesentes.
08. ___Family Therapy/Terapia Familia.
09. ___Substance Abuse Counseling/Consejeria sobre drogas.
10. ___Child Abuse & Neglect Counseling/Consejeria en Abuso Y Descuido de Niños.
11. ___Spiritual Counseling/Consejeria Espiritual.
12. ___Suicide Counseling/Consejeria sobre el Suicidio.
13. ___Depression/Deprecion.
14. ___Loneliness/Soledad.
15. ___Stress/Reduction/Coping/Tension/Reduccion/Afrentarse.
16. ___Gang Prevention/Prevencion de Pandillas.
17. ___Friends to talk to/Amigos conquien Hablar.
18. ___Discrimination Counseling/ Consejeria en Descriminacion.
19. ___Other (Please make a list)/Otros (Por favor haga una lista)
__________________________________________________________________________________________
__________________________________________________________________________________________
CHILD DEVELOPMENT NEEDS/NECESIDADES DEL DESAROLLO DE NINOS:
01. ___Positive Discipline/Deciplina Positiva.
02. ___Stages of Growth/Etapas de Crecimiento.
03. ___Communication/Comunicacion.
04. ___Learning Disabilities/Aprender Incapacidades.
05. ___Learning Activities/Actividades de Aprender.
06. ___Play Activities/Actividades para Jugar.
07. ___Nutrition/Nutricion.
08. ___Other (Please make a list)/Otros (Por favor haga una lista).
EDUCATIONAL NEEDS/NECESIDADES EDUCATIVAS:
01. ___Parenting Classes/Clases de Paternidad.
02. ___Literacy Classes/ Clases de Capacidad de Leer y Escribir.
03. ___English Classes/Clases de Ingles.
04. ___English as Second Language/Ingles como Segundo Idioma.
05. ___Vocational Training/Entrenamiento Vocaccional.
06. ___Family Planning/Planificacion Familiar.
07. ___G.E.D. Classes/Clases en Education General.
08. ___Adult Education or High School Completion/Educacion de Adultos o Preparacion de Secundaria.
09. ___Higher Education J.C. or University/Educacion mas alta de Colegio o Universidad.
10. ___Financial Aide/Asistencia Financiera.
11. ___Self Esteem Classes/Clases en Auto Estima.
12. ___Other (Please make a list)/Otros (Por favor haga una lista)
Page 2 of 3
Parent’s Needs Assessment
PARENT MEETING TOPICS/TEMAS PARA JUNTA DE PADRES”:
01. ___Aids Prevention/Prevencion de Sida.
02. ___First Aide/Primeros Auxcilios.
03. ___Fire Safety/Seguridad de Fuego.
04. ___Earthquake Preparation/Preparacion de Tremolos.
05. ___Nutrition/Nutricion.
06. ___Child Abuse Prevention/Prevencion de Abuso de ninos.
07. ___Community Resources/Recursos de la Comunidad.
08. ___Health Talks/Platicas en la Salud.
09. ___Fight Discrimination/Peliar Discriminacion.
10. ___Drug Babies/Infantes de Drogas.
11. ___Alcohol Fetal Syndrome/Sindrome de alcoholismo del Feto.
12. ___Other (Please make a list)/ Otros (Por favor haga una lista).
__________________________________________________________________________________________
__________________________________________________________________________________________
RESOURCES AND REFERRALS/RECURSOS Y REFERIENCIAS:
01. ___Hotline Numbers/Linea de Informacion.
02. ___Medical Assistance/Asistencia Medica.
03. ___Dental Assistance/Asistencia Dental.
04. ___Psychological Assistance/Asistencia Psycologica.
05. ___Support Group/ Grupo de Apoyo.
06. ___Spiritual Assistance/Asistencia Espiritual.
07. ___Legal Aide Assistance/Asistencia de Ayuda Legal.
08. ___Other (Please make a list)/Otros (Por favor haga una lista)
_______________________________________
Parent’s Signature/Firma de Padres
___________________________
Date/Fecha
Page 3 of 3
Parent’s Needs Assessment
EARLY CHILDHOOD SERVICES
Parent’s Name:
Phone:
PARENT SKILLS INVENTORY:
It is important that Plaza Child Development Programs maintain its Centers and presents an excellent program
of activities for the children. Parents have many skills which can be utilized to accomplish these two
components of our program. The program needs parent’s assistance. It will help us to organize our effort if we
know which skills our program parent’s posses.
We are requesting that you place a check mark () next to any of the activities or skills listed below which you
are willing to make available to the children and the program:
CLASSROOM/OFFICE
BUILDING REPAIR
Pouring, Finish
Dry Wall, Install
Taping
Door Hanging
Window Install
Repair Toys
Repair Equipment
Repair Other
Masonry
Plumbing
Electrician
Furniture Making
Painting
Fence Installation
Carpet Laying
Tile Setting
Linoleum Laying
Carpenter
Mechanic
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
APPLIANCE REPAIR
Washer
_____
Dryer
_____
Television
_____
CD Player
_____
Computer
_____
DVD
_____
Other
_____
LEADERSHIP
Classroom Meeting
Policy Council
Community Outreach
Parent Signature
Field Trip Supervisor
Typing
Office Work
Gardening
Cooking
Sewing
Mending
Pattern Cutting
Cleaning
Waxing Floors
Poetry
Writing
Wash Blankets
Care & Supervise
Drawing
Painting
Musical Instrument
Dancing
Sculpting
Story Telling
Singing
Acting
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
OTHER
List anything else you would like to help with
_______
_____
_____
_____
______
Date
(eac 09/29/13, 06/29/
PLAZA EARLY CHILDHOOD SERVICES
RELEASE FORM
CENTER-BASED FIELD TRIP AUTHORIZATION
Do Not Authorize Center-Based Field Trips
I hereby authorize Plaza Child Development Programs to take my child,
, on
educational field trips during my child’s enrollment in the program. I understand that only children registered
with Plaza Child Development Programs in center-based programs are insured on any school sponsored
activity regardless of where it is, including transportation to and from the location regardless of who is
providing transportation.
I also consent medical treatment as needed for my child in case of an emergency.
FCCHEN FIELD TRIP AUTHORIZATION
Do Not Authorize FCCHEN Walking Field Trips
I hereby authorize my child’s active Provider within Plaza’s FCCHEN to take my child on walking educational
field trips only, during my child’s enrollment in the program. I understand that it is my responsibility to ensure
that my child’s assigned Provider has adequate insurance to take my child on walking educational field trips.
I also consent medical treatment as needed for my child in case of an emergency.
MEDIA COVERAGE AUTHORIZATION
Do Not Authorize Media Coverage
I understand that at various times my child may appear on television, newspaper or other Media coverage
during his or her involvement with Plaza Child Development Programs.
CONSENT FOR RELEASE OF RECORDS AND INFORMATION
I, the undersigned, hereby consent to, request and authorize any and all persons or agencies at Plaza Child
Development Programs to release any or all medical, social, psychological, educational and family file records
to appropriate staff, entities and agencies (i.e. Law Enforcement, California Department of Social Services,
Child Care Licensing Division, Calfiornia Department of Education, Child Development Division, California
Department of Education, Nutritional Services Division, Auditors, etc.). I understand that all such information
shall be made without the parent’s prior written consent and will be used to review program quality and to plan
services. Parents shall have full access to all information contained in their child(ren)’s individual basic data
file.*
* Note: Authorization for release of Records and Information is required or child care/child
development services cannot be provided.
A photocopy of this authorization is as valid as the original
_________________________________
Parent’s Signature
__________________
Date
.
(eac 9/2013, 03/2015, 06/2015)
PLAZA EARLY CHILDHOOD SERVICES
CHILD SUPPORT AND SPOUSAL SUPPORT DECLARATION
Child Support and Spousal Support payments are considered part of a family’s total countable income.
I,
, hereby declare the following is true and accurate.
Parent/Guardian Name
CHECK ALL THAT APPLY
I am RECEIVING a total of $
child(ren).
in child support per month for the following
Child’s Name___________________________________________________
Child’s Name___________________________________________________
Child’s Name___________________________________________________
Child’s Name___________________________________________________
I am NOT receiving child support at this time for the following child(ren).
Child’s Name___________________________________________________
Child’s Name___________________________________________________
Child’s Name___________________________________________________
Child’s Name___________________________________________________
I am RECEIVING a total of $_______________ in spousal support per month.
I am PAYING a total of $__________________ in child support per month.
I understand that any fraudulent, false, incomplete, deceitful, or misleading information provided
to Plaza Community Services, Child Development Programs may be grounds for termination of
child care services. I certify, under penalty of perjury, that the information contained on this form
is accurate and correct.
___________________________________________________________
______________________________
Parent/Guardian
06/29/15