1. education
2. school

Membership in East Hills Preschool, Inc.
East Hills Preschool is a parent-owned and operated non-profit corporation. It
represents an exciting and unique endeavor in the field of early childhood
education. The purpose of this corporation is to provide quality pre-elementary
education for children in the East San Jose area. Its goal is to provide for the
young children in this community a superior learning opportunity within a
stimulating and loving environment. The director and teachers who are responsible
for the educational program are highly qualified and exceed the state educational
requirements. The school has made it their policy to maintain a ratio of three
teachers to every group of twenty-four students.
Members of East Hills Preschool, Inc. include all parents of children enrolled in the
school, the school staff and all other interested parties. An annual fee is required
for membership. Each member is entitled to all voting privileges of the corporation.
Parent involvement has always been a very necessary and vital factor in the
preschool s ability to achieve its goal of maintaining a high standard of education.
The school does rely on proceeds from fund raising activities to augment its
educational program. Upon registration, you are required to sign up for one of the
support committees on the following page.
Welcome to East Hills Preschool!
EAST HILLS PRESCHOOL REGISTRATION FORM
2015 - 2016
I am registering my child:
Child’s Date of Birth:
Other Parent:
Home address:
Cell Phone:
Emergency Contact:
Emergency Contact Phone:
Zip:
Work Phone:
Relation:
Cell Phone:
Parent/Guardian Email:
Doctor Name:
Doctor Phone:
Referred by:
MORNINGS: City:
Home Phone:
Child’s Age:
Parent Name:
Date:
MWF – 8:15 – 11:15 AM
$4,400.00 yearly tuition
TTH – 8:15 – 11:15 AM
$3,300.00 yearly tuition
M - F – 8:15 – 11:15 AM
$7,150.00 yearly tuition
MWF – 12:15 – 3:15 PM
$4,100.00 yearly tuition
TTH – 12:15 – 3:15 PM
$2,800.00 yearly tuition
M – F – 12:15 – 3:15 PM
$6,500.00 yearly tuition
AFTERNOONS:
FINANCIAL AGREEMENT:
I understand that an annual non-refundable membership fee of $150.00 is payable at the time of registration (per
family). PAID
I understand that I am signing a ten-month contract that commits me to payment of ten-months’ tuition, first
installment due July 1. I understand that tuition payments at East Hills Preschool may be made either in one lump sum or in
ten equal installments. In either case, payment is due July 1 for the full year or the first month’s tuition. On the installment
plan, payments are always made in advance, i.e. September tuition is due July 1, October tuition is due September 1, etc.
Initial payments begin on July 1 and continue monthly from September through May. Therefore, accounts paid on time will
have no payment for the month of June. A 10% late fee will be charged after the 15th day of the month.
There are NO refunds or make-ups for days missed due to school holidays, personal vacations or illnesses.
I will give ONE month’s written notice of termination.
In order to insure your slot for September, the membership fee ($150.00) will be due at the time of registration.
Failure to comply will result in your slot being filled with the next name on the waiting list.
I have read and concur with the Enrollment Agreement given to me.
RELEASE OF PHOTOGRAPHS:
By submitting this registration, I agree that EHPS may use photographs or video including my child for promotional use,
education activities, exhibitions, or for any other use for the benefit of the program. I understand that EHPS will not
publish names associated with the likeness of any child on the internet. Allowing photo usage ensures that my child will be
included in any end-of-the-year slideshow or yearbook efforts that may occur.
By initialing here, I agree to the above photo release:
By initialing here, I opt-out of the above photo release:
Signature of Parent or Guardian:
EAST HILLS PRESCHOOL ENROLLMENT AGREEMENT
Financial Agreement: The obligation of the parents/guardians, hereafter called “parents”
for the student’s enrollment during subject period are fully set forth in the East Hills
Preschool Registration Form and by this reference made a part hereof.
Tuition Policy: East Hills Preschool (EHPS) has many expenses of a continuing
nature, such as faculty salaries and plant maintenance. In order to plan and
maintain these services, it is essential that the annual income from tuitions be assured.
For this reason, students are enrolled for the entire academic year or that portion
remaining after date of entry. No tuition reduction or refund will be made for a
student’s absence, illness, late arrival, suspension, expulsion, or withdrawal. The ONLY
exception to this policy is in the event that parents voluntarily withdraw a student 30
days after sending a written notice by mail to the school and first tuition payment,
required to hold a student’s place in class (this payment is made on July 1), is never
refunded if the school is not at full enrollment. Withdrawal notice delivered verbally or
by other means shall NOT be considered sufficient under this Agreement. After the
student’s withdrawal, a pro-rated refund of tuition shall be made based upon the number
of months remaining in the academic year after 30 days from the end of the month in
which notice of withdrawal was received by EHPS. (The Board of Directors reserves the
right to waive tuition for an existing student based on extenuating circumstances.) A
student’s withdrawal terminates membership in the corporation.
A late fee of 10% will be assessed after the 15th of each month. The 10% late fee will
continue to be applied for each month the past due balance remains unpaid. If tuition
payments are more than 25 days past due, institutions of student suspension proceedings
is required. It is also understood and agreed that students whose tuition is not paid when
due may not be permitted to continue in EHPS until the tuition is paid in full.
Parents are required to keep a current credit card on file. For overdue accounts, EHPS
reserves the right to charge any and all past due charges via credit card. The credit card
will only be charged if there is an outstanding balance as of the following dates in the
year: November 15, February 15, May 15, and June 15
In the event that parents fail to fulfill any of the requirements of the Agreement,
and EHPS incurs collection costs as a result, parents agree to pay all collection or
other costs, including reasonable attorney’s fees. The Board of Directors reserves the
right to amend the tuition policy at any time.
Revised 1/28/15
1
Student Suspension or Expulsion: Subject to final decision by the Board of Directors,
EHPS Directors hired by the Board may suspend or expel any student if, in their opinion,
there is convincing evidence of student misconduct, inappropriate behavior or failure
to adhere to school policies and regulation.
An example of misconduct is behavior that is continually disruptive or potentially harmful
to the child or others. Failure of a parent, guardian, or other family member to adhere to
school policies and regulations shall also constitute grounds for suspension or expulsion.
Transportation: Transportation of students to and from EHPS shall be the sole
responsibility of parents.
Late Pick-up: Pick up times are 11:15-11:30 AM and 3:15-3:30 PM. IT IS IMPORTANT
THAT YOU BE PROMPT. A late pick-up fee of $10 per every fifteen minutes or part
thereof past the designated pick-up time shall be charged. THREE (3) occurrences shall
result in a $100 fee and shall be subject to review by the Board of Directors. If a
student has not been picked up within one hour of class dismissal, and the staff has been
unable to reach parents and emergency contact persons through reasonable means, the
Child Protective Services may be called by the Directors.
Consent to Student Participation and Emergency Medical Treatment Authorization:
Permission is hereby granted for the student to participate in any and all recreational
activities and other EHPS-sponsored activities, as well as full participation in the
education program of EHPS. Parents agree to the transport of Student in vehicles owned,
rented, or borrowed by EHPS or its agents for any reasonable purpose, at any time during
the academic year.
In connection with the foregoing and pursuant to California Code Section 28.8: We,
the parents or guardians of the above minor child, do hereby authorize the adult leaders,
teachers, administrators, or other proper agents of EHPS to act as agents for the
undersigned to consent to any X-ray, examination, anesthetic, medical or surgical
diagnosis or treatment and hospital care for the above minor child which is deemed
advisable and to be rendered under the general or special supervision of a physician or
dentist, at a hospital, school or elsewhere. This authorization will remain effective while
the above child is en route to or from, or involved or participating in any EHPS program or
activity, unless revoked in writing by the parent or guardian and delivered to the
aforesaid agent. Consent is also herewith given EHPS for any first aid treatment of the
Student which is deemed advisable by EHPS, its Directors, teachers, or other agents, for
any condition which, in the exercise of their sole discretion, is deemed to be of any
emergency nature.
Revised 1/28/15
2
Release and Indemnity: In consideration of EHPS allowing the student and or
parents to participate in school activities, the Student and parents waive all right, title
and interest in and to any claim or cause of action which they may have against
EHPS, its agents or employees for any and all injuries which may occur to them and/or
their property related to such employees. The Student and parents also agree to
indemnify and hold harmless EHPS, its agents or employees from any and all injuries
which may be caused to persons or property and which may result from any act or
omission by Student or parents.
Consent to Testing and Release of Records: Parents hereby authorize release to EHPS
of transcripts, medical, educational, behavioral and psychological records, and any related
information that may be deemed desirable for student evaluation or educational planning
by EHPS. Parents further authorize the administration of such test as deemed useful by
EHPS for student evaluation or counseling and/or EHPS program planning or evaluation.
Consent to Release of Child’s Photographs: By submitting this registration, I agree
that EHPS may use photographs or video including my child for promotional use, education
activities, exhibitions, or for any other use for the benefit of the program. I
understand that EHPS will not publish names associated with the likeness of any
child on the internet. Allowing photo usage ensures that my child will be included in any
end-of-the-year slideshow or yearbook efforts that may occur. I may decline this photo
release as instructed on the registration form.
Increase of Tuition: The Board of Directors reserves the right to increase all
annual Tuition fees, and accordingly, the payments required of the parents to meet said
obligation, as well as the additional charges enumerated below on sixty (60) days prior to
written notice: provided, however, that said increased charges will not be made
retroactively, but only prospectively on subject notice, and then only for the express
purpose of meeting all of the School’s necessary expenses to maintain the quality
standard of its programs contemplated at the commencement of the School year, as nonprofit serving the benefit of the Student, his/her parents and the School’s faculty.
Refund, Credits, and the Adjustments: No refund, credits or adjustments shall be
allowed for a Student’s absenteeism, regardless of the reason thereof.
Miscellaneous Charges: In addition to their obligation for tuition, parents shall pay to
the school, at the time the Registration Form is signed by them, an annual fee which is
non-refundable.
Revised 1/28/15
3
Force Majeure: In the event that a campus is closed because of a natural catastrophe,
war, strike, civil emergency, or other circumstance beyond the control of EHPS, this
contract shall remain in full force and effect, but EHPS shall be obliged to provide
additional instructional days during or immediately following the end of the academic year
or, at the option of EHPS, to refund a pro-rated sum equal to the instructional day(s)
lost.
Extent of Agreement and Notices: The Registration Form referenced in the
Agreement is a part hereof and together make up the entire Agreement between the
parties. No verbal agreement exist between the parties. This Agreement cannot be
varied, altered, or amended, except by the WRITTEN agreement executed by all parties
hereto. If any provision or provisions of the Agreement are held invalid, such invalidity
shall not affect the other provisions hereof which shall not affect the other provisions
hereof which shall continue in full force and effect. All notices relative to the Agreement
shall be sent to the Administrative Office of the School. A notice required to be sent by
either party hereto shall be deemed sufficient only if is in writing and sent by United
States mail to the last known address of the party to whom the notice is to be given.
Please acknowledge with your signature below that you read all four pages of the above
Agreement, and that you accept it.
Parent’s Name
Signature
Child’s Name
Date
Revised 1/28/15
4
EAST HILLS PRESCHOOL TUITION POLICIES
The Board of Directors of East Hills Preschool (EHPS) has adopted the following Tuition
Policies and requires that registered families read, agree to, and sign the following form
in order to complete registration:
1. Tuition may be paid either in one lump sum or in ten equal installments.
a. One lump sum – Due July 1, 2015
b. Installment tuition plan (ten equal installments)
1st installment due July 1, 2015 (September dues)
No payment is made in August
2nd installment due September 1, 2015 (October dues) & monthly
installments continue each month thereafter, always due on the 1st of the
month, until final payment on May 1, 2016.*
*Those in arrears, or those who started mid-year and did not make the first
in-advance payment may require a payment in June 2016.
2. Tuition is due the first of each month and considered late after the 15th of the
month. A 10% late charge will be added at that time.
3. The policy of EHPS shall be to charge a fee of $25.00 for checks that are returned
unpaid from the bank.
4. EHPS allows families to resign from the school with 30 days written notice. However,
in the event that a student resigns prior to the start of the school year in September
and the school is not at full enrollment, the first installment payment of tuition is
non-refundable. Additionally, any family that resigns later than April 1 of any school
year is expected to pay tuition in full through June.
5. Parents are required to keep a credit card on file. For overdue accounts, EHPS
reserves the right to charge any and all past due charges via credit card. The credit
card will only be charged if there is an outstanding balance as of the following dates
in the year: November 15, February 15, May 15, and June 15
6. The Board of Directors reserves the right to waive the tuition for an existing
student based on extenuating circumstances.
I HAVE READ AND AGREE TO THE ABOVE TUITION POLICIES
Parent’s Name
Signature
Child’s Name
Date
Credit Card Number
Type
Expiration
Security Code
EAST HILLS PRESCHOOL PARTICIPATION POLICY
In order to minimize tuition costs, it is the policy of East Hills Preschool to
require each family to contribute time and effort in the operation and
management of the preschool through:
Participation on one committee OR on the Board of Directors
Attendance of up to 2 General Corporation Meetings
Attendance at 1 Parent Education Meeting
As a member of a committee, you will also be providing support for
the Auction
As a condition of enrollment, at least one adult member of each family is
required to sign up for a minimum of one committee assignment or Board of
Directors position, attend committee meetings throughout the school year
and actively contribute time and effort towards the accomplishment of the
committee’s objectives as detailed by the committee. And, each family must
be represented at the (up to) 2 General Corporation meetings and attend at
least 1 Parent Education Night. (Parent Education night may be combined
with one of the General Meetings. If you absolutely cannot attend the
General Meeting, your proxy vote must be received by the Preschool.)
In the event that a family does not fulfill any part of the participation
requirements, the Board of Directors has the right to charge the $300.00
Non-Participation Fee, payable to the Preschool by January 1, 2016. If the
payment is not settled, a collection agency may be called to rectify.
I/We
understand that
in the event that I/we do not fulfill the participation requirements as stated
above, I/we may be assessed, and I/we agree to pay, a non-participation fee
of $300.00. I/we understand that this assessment will be made and
approved by a majority vote of the Board of Directors.
Name:
Signature:
Date:
EAST HILLS PRESCHOOL COMMITTEE SIGN-UPS
2015 - 2016
PARENT(S) NAME(S): _________________________________________________
CHILD’S NAME:
________________________ CHILD’S CLASS:_____________
ADDRESS:
___________________________________________________
HOME PHONE:
__________________ CELL PHONE: ______________________
EMAIL ADDRESS(S): __________________________________________________
Please mark your 1st, 2nd and 3rd choices below.
I would like to be a candidate for the Board of Directors:
President
Social/Hospitality Liaison
Vice President
Fundraising/Scrip Committee Chairperson
Secretary
Work Party Committee Chairperson
Treasurer
Personnel Chairperson
Parent Coordinator
Auction Chairperson
Alternate
Marketing Chairperson
I would like to be a member of the following committee:
Work Party Committee
Social/Hospitality Committee
Marketing/Registration Committee
Auction Committee
Fundraising Committee
AF/NP – I want to pay the fee of $300.00 and NOT participate on a committee.
Revised 1/28/15
East Hills Preschool
14845 Story Road, San Jose, CA 95127
(408) 923-8616
Skills Form
Child(ren)’s Name:________________________________ Class:___________________
Father’s Name:____________________________ Occupation:_____________________
Phone:______________________ E-mail: _______________________________________
Mother’s Name: ___________________________ Occupation:_____________________
Phone:______________________ E-mail: _______________________________________
Do you or your spouse have any of these skills? (Please check)
Legal Expertise
Marketing
Grant Writing
HR Expertise
Web Development
Fundraising
Plumbing
Graphic Design
Event planning
Construction
Photography
Sewing
IT/ Computers
Gardening
Communications
Do you know of anyone who may be interested in substitute teaching?
Yes
No
Name of Teacher: __________________________________________________________
Phone:______________________ E-mail: _______________________________________
East Hills Preschool
14845 Story Road, San Jose, CA 95127
(408) 923-8616
Medical Release Consent Form
Child’s Name:
Date of Birth:
Parent’s Name:
Phone:
Address:
City:
Zip:
In the event that my child becomes ill or sustains an injury while in the care of
East Hills Preschool, I give permission to those in charge to take whatever steps
are necessary. If it is not possible to reach the doctor named below or to receive my
instruction for his/her care, consent is given to any licensed physician and/or
surgeon to whom my child is taken for treatment, to administer drugs or
medications, and perform such surgical procedures as he/she shall think the
emergency requires or for the relief of pain and to preserve life and health.
My child,
, does/ does not have known allergies
to drugs and medication. (Please list any known allergies to drugs or medication
under “COMMENTS”.)
Date
Signature of Parent/Guardian
Physician’s Name:
Phone: (
)
Dentist’s Name:
Phone: (
)
Insurance
Medical
Dental
Group Plan:
Group Plan:
I.D.:
I.D.:
Coverage:
Coverage:
Special Instructions:
Please attach a copy of insurance and please notify our office immediately of any
changes to your insurance.
Comments:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CONSENT FOR EMERGENCY MEDICAL TREATMENTChild Care Centers Or Family Child Care Homes
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
East Hills Preschool
_________________________________________
TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE
FACILITY NAME
PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR
__________________________________________________ . THIS CARE MAY BE GIVEN UNDER
NAME
WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD
NAMED ABOVE.
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:
DATE
PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE
HOME ADDRESS
HOME PHONE
WORK PHONE
(
(
)
LIC 627 (9/08) (CONFIDENTIAL)
)
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
IDENTIFICATION AND EMERGENCY INFORMATION
CHILD CARE CENTERS/FAMILY CHILD CARE HOMES
To Be Completed by Parent or Authorized Representative
CHILD’S NAME
LAST
ADDRESS
NUMBER
MIDDLE
FIRST
SEX
TELEPHONE
(
STREET
FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME
CITY
LAST
STATE
MIDDLE
ZIP
FIRST
BUSINESS TELEPHONE
(
HOME ADDRESS
NUMBER
STREET
CITY
STATE
ZIP
LAST
MIDDLE
FIRST
NUMBER
STREET
CITY
STATE
ZIP
LAST NAME
MIDDLE
FIRST
)
HOME TELEPHONE
(
PERSON RESPONSIBLE FOR CHILD
)
BUSINESS TELEPHONE
(
HOME ADDRESS
)
HOME TELEPHONE
(
MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME
)
BIRTHDATE
)
HOME TELEPHONE
BUSINESS TELEPHONE
(
(
)
)
ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY
NAME
ADDRESS
TELEPHONE
RELATIONSHIP
PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY
PHYSICIAN
ADDRESS
MEDICAL PLAN AND NUMBER
DENTIST
ADDRESS
MEDICAL PLAN AND NUMBER
TELEPHONE
(
)
TELEPHONE
(
)
IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?
■ CALL EMERGENCY HOSPITAL
■ OTHER
EXPLAIN: ____________________________________________________________________________________________________________________
NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY
(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)
NAME
RELATIONSHIP
TIME CHILD WILL BE CALLED FOR
SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE
DATE
TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE
DATE OF ADMISSION
LIC 700 (8/08)(CONFIDENTIAL)
DATE LEFT
STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT
CHILD’S NAME
SEX
BIRTH DATE
FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME
DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME
DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?
DATE OF LAST PHYSICAL/MEDICAL EXAMINATION
DEVELOPMENTAL HISTORY (*For infants and preschool-age children only)
WALKED AT
*
BEGAN TALKING AT
MONTHS
*
TOILET TRAINING STARTED AT
MONTHS
*
MONTHS
PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:
DATES
DATES
DATES
■
Chicken Pox
■
Diabetes
■
Poliomyelitis
■
Asthma
■
Epilepsy
■
■
Rheumatic Fever
■
Whooping cough
Ten-Day Measles
(Rubeola)
■
■
Hay Fever
■
Mumps
Three-Day Measles
(Rubella)
SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS
■
DOES CHILD HAVE FREQUENT COLDS?
YES
■
NO
HOW MANY IN LAST YEAR?
LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF
DAILY ROUTINES (*For infants and preschool-age children only)
*
WHAT TIME DOES CHILD GET UP?
*
WHAT TIME DOES CHILD GO TO BED?
DOES CHILD SLEEP DURING THE DAY?
DIET PATTERN:
(What does child usually
eat for these meals?)
*
WHEN?
DOES CHILD SLEEP WELL?
*
*
*
HOW LONG?
BREAKFAST
WHAT ARE USUAL EATING HOURS?
BREAKFAST ________________________
LUNCH_____________________________
LUNCH
DINNER
DINNER
ANY FOOD DISLIKES?
ANY EATING PROBLEMS?
*
IS CHILD TOILET TRAINED?
■
YES
■
IF YES, AT WHAT STAGE:
*
NO
WORD USED FOR “BOWEL MOVEMENT”
ARE BOWEL MOVEMENTS REGULAR?
■
YES
■
WORD USED FOR URINATION
*
*
WHAT IS USUAL TIME?
*
NO
*
PARENT’S EVALUATION OF CHILD’S HEALTH
IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?
■
YES
■
YES
■
DOES CHILD TAKE PRESCRIBED MEDICATION(S)?
■
NO
DOES CHILD USE ANY SPECIAL DEVICE(S):
■
IF YES, NAME OF DOCTOR:
IF YES, WHAT KIND:
NO
YES
■
IF YES, WHAT KIND AND ANY SIDE EFFECTS:
NO
DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME? IF YES, WHAT KIND:
■
YES
■
NO
PARENT’S EVALUATION OF CHILD’S PERSONALITY
HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?
HAS THE CHILD HAD GROUP PLAY EXPERIENCES?
DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)
WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?
REASON FOR REQUESTING DAY CARE PLACEMENT
PARENT’S SIGNATURE
LIC 702 (8/08) (CONFIDENTIAL)
DATE
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHILD CARE CENTER
NOTIFICATION OF PARENTS’ RIGHTS
PARENTS’ RIGHTS
As a Parent/Authorized Representative, you have the right to:
1.
Enter and inspect the child care center without advance notice whenever children are in care.
2.
File a complaint against the licensee with the licensing office and review the licensee’s public file
kept by the licensing office.
3.
Review, at the child care center, reports of licensing visits and substantiated complaints against the
licensee made during the last three years.
4.
Complain to the licensing office and inspect the child care center without discrimination or retaliation
against you or your child.
5.
Request in writing that a parent not be allowed to visit your child or take your child from the child
care center, provided you have shown a certified copy of a court order.
6.
Receive from the licensee the name, address and telephone number of the local licensing office.
Licensing Office Name:
Department of Social Services Community Care Licensing
_________________________________________________
Licensing Office Address:
2580 N. 1st Street #300 San Jose, CA 95131
_________________________________________________
Licensing Office Telephone #:
(408) 324-2148
_________________________________________________
7.
Be informed by the licensee, upon request, of the name and type of association to the child care
center for any adult who has been granted a criminal record exemption, and that the name of the
person may also be obtained by contacting the local licensing office.
8.
Receive, from the licensee, the Caregiver Background Check Process form.
NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO A
PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE
POSES A RISK TO CHILDREN IN CARE.
For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov
LIC 995 (9/08)
(Detach Here - Give Upper Portion to Parents)
A C K N O W L E D G E M E N T O F N O T I F I C AT I O N O F PA R E N T S ’ R I G H T S
(Parent/Authorized Representative Signature Required)
I, the parent/authorized representative of ________________________________________________, have
received a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and the
CAREGIVER BACKGROUND CHECK PROCESS form from the licensee.
East Hills Preschool
_____________________________________
Name of Child Care Center
______________________________________________
Signature (Parent/Authorized Representative)
NOTE:
__________________
Date
This Acknowledgement must be kept in child’s file and a copy of the Notification given to
parent/authorized representative.
For the Department of Justice “Registered Sex Offender”database go to www.meganslaw.ca.gov
LIC 995 (9/08)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONAL RIGHTS
Child Care Centers
Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.
(a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are
not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her
needs.
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,
threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily
living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to
physical functioning.
(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the
provisions of law regarding complaints including, but not limited to, the address and telephone number of the
complaint receiving unit of the licensing agency and of information regarding confidentiality.
(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor
of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely
voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from
spiritual advisors shall be made by the parent(s), or guardian(s) of the child.
(6) Not to be locked in any room, building, or facility premises by day or night.
(7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing
agency.
THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE
LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:
NAME
Department of Social Services Community Care Licensing
ADDRESS
2580 N 1st Street #300
CITY
ZIP CODE
San Jose, CA
95132
AREA CODE/TELEPHONE NUMBER
(408) 324-2148
DETACH HERE
TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE:
PLACE IN CHILD'S FILE
Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:
ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the
California Code of Regulations, Title 22, at the time of admission to:
(PRINT THE NAME OF THE FACILITY)
East Hills Preschool
(PRINT THE ADDRESS OF THE FACILITY)
14845 Story Road, San Jose, CA 95127
(PRINT THE NAME OF THE CHILD)
(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)
(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN)
LIC 613A (8/08)
(DATE)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
PHYSICIAN’S REPORT—CHILD CARE CENTERS
(CHILD’S PRE-ADMISSION HEALTH EVALUATION)
PART A – PARENT’S CONSENT (TO BE COMPLETED BY PARENT)
__________________________________________, born ________________________________ is being studied for readiness to enter
(NAME OF CHILD)
(BIRTH DATE)
East Hills Preschool
_________________________________________
. This Child Care Center/School provides a program which extends from _____ : ____
(NAME OF CHILD CARE CENTER/SCHOOL)
a.m.p.m. to ______ BBBBa.m.p.m. , __________ days a week.
Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this
report to the above-named Child Care Center.
__________________________________________________________
(SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE)
_________________
(TODAY’S DATE)
PART B – PHYSICIAN’S REPORT (TO BE COMPLETED BY PHYSICIAN)
Problems of which you should be aware:
Hearing:
Allergies: medicine:
Vision:
Insect stings:
Developmental:
Food:
Language/Speech:
Asthma:
Dental:
Other (Include behavioral concerns):
Comments/Explanations:
MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:
IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)
DATE EACH DOSE WAS GIVEN
VACCINE
1st
POLIO (OPV OR IPV)
DTP/DTaP/
DT/Td
(DIPHTHERIA, TETANUS AND
[ACELLULAR] PERTUSSIS OR TETANUS
AND DIPHTHERIA ONLY)
(MEASLES, MUMPS, AND RUBELLA)
MMR
(REQUIRED FOR CHILD CARE ONLY)
(HAEMOPHILUS B)
HIB MENINGITIS
HEPATITIS B
VARICELLA
(CHICKENPOX)
2nd
3rd
4th
5th
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
SCREENING OF TB RISK FACTORS (listing on reverse side)
■ Risk factors not present; TB skin test not required.
■ Risk factors present; Mantoux TB skin test performed (unless
previous positive skin test documented).
___ Communicable TB disease not present.
I have
■
have not
■
reviewed the above information with the parent/guardian.
Physician:_______________________________________________
Address:________________________________________________
Telephone: ______________________________________________
Date of Physical Exam: ___________________________________
Date This Form Completed: _______________________________
Signature ______________________________________________
■
LIC 701 (8/08) (Confidential)
Physician
■
Physician’s Assistant
■
Nurse Practitioner
PAGE 1 OF 2
RISK FACTORS FOR TB IN CHILDREN:
*
Have a family member or contacts with a history of confirmed or suspected TB.
*
Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America).
*
Live in out-of-home placements.
*
Have, or are suspected to have, HIV infection.
*
Live with an adult with HIV seropositivity.
*
Live with an adult who has been incarcerated in the last five years.
*
Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents in
nursing homes.
*
Have abnormalities on chest X-ray suggestive of TB.
*
Have clinical evidence of TB.
Consult with your local health department’s TB control program on any aspects of TB prevention and treatment.
LIC 701 (8/08) (Confidential)
PAGE 2 of 2
EAST HILLS PRESCHOOL
SIGNED HEALTH POLICY
I hereby understand that for the health and well being of my child, the
students enrolled in EHPS, and it’s staff members, I will be prohibited from
bringing my child to school in event of his/her illness. An illness will be
assumed with any of the following conditions, and the student must be kept
home for at least 24 hours after illness:
Fever
Vomiting
Diarrhea
Profuse runny nose
Sore throat
Severe coughing
Pinkeye
Unusual spots or rashes
Infected skin patches
I will return all mandated health forms. The following immunizations are
required: Polio (3 doses), DTP (4 doses), MMR, HIB, Hepatitis B and
Varicella (Chicken Pox). A TB screening as referred to by the child’s
pediatrician. Refer to Physician’s Report.
Call the school whenever your child will be absent (408-923-8616) and
notify us if your child contracts a contagious disease. Please sign the form,
keep one copy, and return the other to the school for your child’s file.
Name_____________________
Date______________________
Signature_______________________
East Hills Preschool
14845 Story Road, San Jose, CA 95127
(408) 923-8616
Child Information Form
Child’s Formal Name
Child’s Name
Child’s Name
(e.g., William Brady):
as you prefer them to be
addressed in class (e.g., Will)
as you would like them to practice
writing for school (e.g., William)
Date of Birth:
Place of Birth:
Allergies:
Special Needs:
Adults that live in home and their
relationship to child
Name
Relationship
Names and ages of siblings
Name
Age
Other significant adults in child’s life (grandparents, nanny, etc.)
Name
Relationship
Animals:
Is your child permitted to handle classroom animals?
Yes
No
Is there another language spoken at home?
Yes
No
If yes, what language?
Other relevant information:
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IMPORTANT INFORMATION FOR PARENTS
CAREGIVER BACKGROUND CHECK PROCESS
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
The California Department of Social Services works to protect the safety of children in child care by
licensing child care centers and family child care homes. Our highest priority is to be sure that children
are in safe and healthy child care settings. California law requires a background check for any adult
who owns, lives in, or works in a licensed child care home or center. Each of these adults must submit
fingerprints so that a background check can be done to see if they have any history of crime. If we
find that a person has been convicted of a crime other than a minor traffic violation or a marijuanarelated offense covered by the marijuana reform legislation codified at Health and Safety Code
sections 11361.5 and 11361.7, he/she cannot work or live in the licensed child care home or center
unless approved by the Department. This approval is called an exemption.
A person convicted of a crime such as murder, rape, torture, kidnapping, crimes of sexual violence or
molestation against children cannot by law be given an exemption that would allow them to own,
live in or work in a licensed child care home or center. If the crime was a felony or a serious
misdemeanor, the person must leave the facility while the request is being reviewed. If the crime is
less serious, he/she may be allowed to remain in the licensed child care home or center while the
exemption request is being reviewed.
How the Exemption Request is Reviewed
We request information from police departments, the FBI and the courts about the person’s record.
We consider the type of crime, how many crimes there were, how long ago the crime happened and
whether the person has been honest in what they told us.
The person who needs the exemption must provide information about:
• The crime
• What they have done to change their life and obey the law
• Whether they are working, going to school, or receiving training
• Whether they have successfully completed a counseling or rehabilitation program
The person also gives us reference letters from people who aren’t related to them who know about
their history and their life now.
We look at all these things very carefully in making our decision on exemptions. By law this information
cannot be shared with the public.
How to Obtain More Information
As a parent or authorized representative of a child in licensed child care, you have the right to ask the
licensed child care home or center whether anyone working or living there has an exemption. If you
request this information, and there is a person with an exemption, the child care home or center must
tell you the person’s name and how he or she is involved with the home or center and give you the
name, address, and telephone number of the local licensing office. You may also get the person’s
name by contacting the local licensing office. You may find the address and phone number on our
website. The website address is http://ccld.ca.gov/contact.htm.
LIC 995 E (10/09)
East Hills Preschool
14845 Story Road, San Jose, CA 95127
(408) 923-8616
Child Goals and Expectations Form
Child’s Name:
Please list/describe some goals and/or expectations for your child in a preschool
setting (e.g., social skills, counting, number recognition, etc.)
1.
2.
3.
4.
5.
6.
East Hills Preschool
14845 Story Road, San Jose, CA 95127
(408) 923-8616
Emergency Action Plan
In case of an emergency or natural disaster:
v Students may evacuate EHPS and walk to National Hispanic University,
located at 14271 Story Road. (408) 926-6246.
o Students will be supervised by the Program Director and teachers
while off campus.
v Parents will be notified by a board member of what the next steps will be
(e.g., pick-up location, further communication).
o There is a current emergency phone tree in place by the board
members. It is important that each parent keeps all contact
information up to date.
v A more detailed disaster plan is located at the school, next to the front door,
for your reference.
East Hills Preschool
14845 Story Road, San Jose, CA 95127
(408) 923-8616
Emergency Evacuation Plan
The Department of Social Services dictates that East Hills Preschool have a
designated emergency evacuation site. In the event of a natural disaster or national
emergency, our students will be evacuated to:
The National Hispanic University
14271 Story Road
San Jose, CA 95127
(408) 926-6246
East Hills Preschool
14845 Story Road
San Jose, CA 95127
(408) 923-8616
www.easthillspreschool.com
Registration Checklist
School Forms
Student/Family Forms
Registration Form - Original *
Registration Form – Copy *
Enrollment Agreement - Original *
Enrollment Agreement – Copy *
Tuition Policy – Original *
Tuition Policy - Copy *
Participation Agreement - Original *
Participation Agreement - Copy *
Committee Sign-ups – Original *
Committee Sign-ups - Copy *
Skills Form – Original
Handbook - Original
Medical Release - Original *
Caregiver Background Check
Consent of Emergency Treatment – Original *
Emergency Evacuation Plan
Identification & Emergency – Original *
Health & History - Original
Parent’s Rights - Original
Personal Rights - Original
Physician’s Form - Original
Health Policy - Original *
Child Info. Form - Original *
Child Goals and Expectations Form – Original
Please verify that you have received copies of all forms noted in the Student/Family Column.
This checklist stays with the school along with the completed forms noted under School Forms.
*Returning students will receive only the asterisked forms.
Revised 1/28/15