Telephone: (530) 895-8796 FAX: (530) 899-8540

info@superluperkids.com

1450 Springfield Drive #219Chico, CA 95928

Lic# 045404892Lic# 045404411

Baby Registration Packet

Thank you for choosing Super Luper Babies!

Please fill out the entire packet. If you have any questions, please talk to Tara. Do not permanently remove any of the forms.The following forms should be included. If any are missing, please let us know.

• Child care rates• Admissions agreement• Identification and emergency information• Permission slip• Financial agreement• Physician’s report• Child’s pre-admission health history• Notification of parent’s rights• Personal rights• Consent for medical treatment• Immunization record• Infant Center Parent packet & procedures• USDA Food application & enrollment form

Admissions Agreement

Philosophy and GoalsOur philosophy is to provide a loving, enriching environment for the educational emo-tional and physical enjoyment of each baby.Super Luper Babies is a safe haven for your baby. If you’re at work or play, rest assured he/she will be loved, stimulated, and nurtured. We realize each child is unique and special, and we strive to give all children in our care a strong foundation for their future.

Admissions PolicyBefore admitting to Super Luper Babies, a private interview between the Director and prospective clients must take place. At this time all criteria is discussed. Parents must complete all necessary forms (application, financial, medical, emergency, etc.) and have all applicable immunizations cleared (DPT and TB skin test) prior to the child’s admission.

NondiscriminationNo child shall be denied admission because of race, color, ethnic, or religious back-ground. All children attending the facility will be treated equally.

Rights of Licensing DepartmentThe licensing department of the State of California has the right to inspect the facility at any time during the hours of operation.

Clients RightsParents have the right to come and visit the facility at any time during the hours of operation.

Fee ScheduleA schedule of the current fees is included in this package. A 30 day notice will be given for any rate change.

Operational PolicyProper and efficient operation of the center depends on the cooperation of all parents in adhering to contracted school hours. Parents are asked to comply with their contract schedules.1. School hours are from 7:30am – 5:30pm, Monday through Friday. No extensions beyond the normal hours will be permitted. Super Luper Babies is closed weekends and all major holidays. A schedule of holidays is provided every January. Contracted childcare hours cannot be credited and used later. No refunds are given. If your child will be absent for all or any portion of a day, please notify the staff by 10:00am.2. Sign-in and sign-out. Parents must sign their children in and out every day. Parents are requested to sign a full signature. Children are not allowed to sign themselves in or out. Children may not be left at the facility until greeted by a staff member. The health of the child will be observed at this time.3. Late pickups are subject to a fine of $1.00 per minute after 5:30pm.4. Payments. All payments must be made in advance, and preferably on the 13th or 15th of every month. A late fee of $10.00 per day will be charged after the 5th if your bill is due on the 1st , and the 20th if your bill is due on the 15th.

Classroom Environment1. Ages of children. Children ages 0-2 will be accepted at Super Luper Babies.2. Supervision. No child will be left unsupervised at any time for any reason. Parents are responsible for their children upon arrival and departure. Children are not allowed to leave the premises unless accompanied by an adult.3. Staff ratios. The maximum ratio of infants to teacher is 4 to 1.4. Communication. It is important to maintain open communication between the parents and director. This enables us to freely discuss objectives, concerns, goals, etc.5. Discipline. Any form of discipline or punishment, which violates a child’s rights, is prohibited. Toddlers shall be re-directed.

Safety Factors1. No child will be released to anyone other than adults listed on the admission form, unless specified by the parent along with a written permission slip.2. Disaster Plan. In case of a fire, or fire drill, emergency clearance of the building will entail a bell system being activated. Children will exit to the front sidewalk or back play area. A staff member will bring the daily roster to be sure that all children have exited the building. Babies will be carried or seat-belted into the “bye-bye buggy.” All children and staff will meet out in front of the center or sandbox area.3. Medications. Super Luper Babies does not dispense medication.4. Notifying parents of illness or emergency. A parent or guardian will be called to pick up their child immediately if they become ill. In case of an emergency, the parent will be notified and asked to meet a staff person at the medical facility of choice.

Illness1. If your child will be absent due to illness, parents are to notify the staff by 10:00am. The school shall be notified if the child has contracted a communicable disease.2. The center reserves the right to refuse admittance to any child showing signs of illness.3. If a child has been sick, he/she should remain home until he/she is able to participate in a normal school day, including outdoor play.4. If a child has had a fever, he/she is required to stay home for 24 hours after the fever has subsided.

Physical Well Being

1. Personal care: Infant/toddlers being toilet trained will have a written plan provided by the parent. The Director of the center will help develop the plan if the parent desires. The center staff shall have ready access and follow the plan for toilet training. Potty chairs will be provided by the center. Children in the process of being potty trained shall wear clothing that can be easily removed to avoid accidents. Parents shall provide sufficient diapers, training pants, and clothing to ensure that the infant/toddler can be clean and dry at all times. Soiled cloth diapers and clothing shall be sent home at the end of each day in an airtight container provided by the parent.

2. Appropriate clothing: Clothing shall be comfortable, sturdy, and washable. The center cannot be responsible for lost or damaged articles (i.e., unlabeled clothing, toys, etc.).

3. Snacks and lunches: Nutritious snacks and lunches (11:30 – 12:00) will be provided on a daily basis. We ask that the parents refrain from sending candy or sweet snacks to school.

4. Infant/toddler food service: Parents will provide the center with the necessary special foods (baby food, formula, breast milk, etc.) required by their infant/toddler on a daily basis. Formula and milk provided by the parent shall be bottled and labeled with the child’s name before being accepted by the center. Babies will be fed on demand or a minimum of every four hours. The center will heat the bottles to the appropriate tem-perature. Under no circumstances will a bottle be propped for an infant; they will be held during feedings until he/she is able to hold their own unbreakable bottle. A child will not be permitted to walk around and drink a bottle. Commercially prepared baby food jars shall be transferred to a dish before being fed to an infant. Highchairs and infant seats shall be used during feedings. Feeding bowls, utensils, cups and bottles that are provided by the parent shall be taken home and sanitized at the end of each day. In the event the parent forgets to send food, the center shall provide appropriate food for the infant/toddler. Those toddlers capable of eating table foods will be provided with meals by the center.

5. Naptime: Infants and toddlers will nap as needed. Cribs with clean sheets are provided by the center. Bedding will be changed daily or more, if needed. Each infant/toddler will use their bedding only.

6. Infant/toddler care activities: Super Luper Babies is designed to meet the needs of each child, which includes but is not limited to: quiet and active play, rest and relaxation, eating, diaper changing and toileting, individual attention and above all being held, loved, and cuddled by all staff members.

7. Infant center equipment: Inside equipment includes highchairs, padded climbing structures designed for toddlers, height appropriate tables and chairs, and cribs. Outside equipment includes push toys, tables, chairs, grassy area for play and small climbing equipment. A variety of age appropriate toys will always be available.

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___________________________________________ ____________________________Parent Signature Date

Program Description

Our program is designed to meet the emotional, physical and cognitive needs of each baby. Our center is equipped with modern staff, equipment, furnishings, rocking chairs, stimulating and soothing toys and educational gadgets to promote healthy, happy, secure growth. Close working relationships with parents allows us to discuss concerns, objectives and goals openly. This is imperative to any successful relationship.Our goal for your baby is to feel loved and secure, to give your baby strong foundation for growth and development in the future. After all, they are our future.A two week notice shall be given to terminate services, unless the immediate health and well-being of any baby is jeopardized. This would justify immediate termination.

Aggressive BehaviorWe want all our Super Luper Babies safe. Continually aggressive behavior will not be tolerated, such as: biting, pushing, hitting, pulling hair or anything that harms another child. A parent will be called the first incident, the second incident the parent will be asked to pick up their child, and the third incident will result in termination. In between the second and third incidents, parents will be asked to make an appointment with the Director to discuss options and talk about solutions. We’ll make every effort to secure a safe environment for everyone!

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___________________________________________ ____________________________Parent Signature Date

Your Baby!

Dear parents-Please tell us about your baby!This questionnaire will serve as reminders to us, and give you peace of mind, knowing we know all the little things that mean the most to your baby. Please update this infor-mation as needed. Thank you!

• Breast / Bottle:

• Types of formula:

• Types of baby food:

• Types of diapers:

• Allergies:

• Likes:

• Dislikes:

• Sleep Times:

• Sleep Position:

Baby Schedule

7:30-9:00 – Babies arrive. Soothing music and aromas will help your baby start their day feeling calm and secure.

9:00-10:00 – Breakfast is served for toddlers who are on our USDA approved meal plan, posted in our lobby. – Walks in our state of the art BYE BYE BYE BABY Buggy, outside play, swings, etc. Jazzy baby music, finger plays, sensory fun. Old fashion baby fun. Peek-A-Boo, nursery songs and rhymes, books that even babies like!

11:00-12:00 – Baby playtime!

12:00-1:00 – Lunch and lullabies

1:00-3:00 – Sleepy time, nap time

3:00-4:00 – Snacks / mid-afternoon mini meals, cuddles and more stimulating fun!

4:00-5:30 – Parents arrive. Ending each day with playtime fun

Please note: This is a tentative schedule, and will vary to meet the individual needs of each baby.

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PERSONAL RIGHTSChild 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 dailyliving functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids tophysical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of theprovisions of law regarding complaints including, but not limited to, the address and telephone number of thecomplaint 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 advisorof his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completelyvoluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits fromspiritual 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 APPROPRIATELICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

NAME

(PRINT THE NAME OF THE FACILITY)

(PRINT THE NAME OF THE CHILD)

(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)

(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE)

LIC 613A (8/08)

(PRINT THE ADDRESS OF THE FACILITY)

ADDRESS

CITY ZIP CODE AREA CODE/TELEPHONE NUMBER

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 theCalifornia Code of Regulations, Title 22, at the time of admission to:

( )( )

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CONSENT FOR EMERGENCY MEDICAL TREATMENT-Child Care Centers Or Family Child Care Homes

AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO

_________________________________________ 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.

DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE

CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:

HOME ADDRESS

HOME PHONE

LIC 627 (9/08) (CONFIDENTIAL)

WORK PHONE

I have !! have not !! reviewed the above information with the parent/guardian.

Physician:_______________________________________________ Date of Physical Exam: ___________________________________Address:________________________________________________ Date This Form Completed: _______________________________Telephone: ______________________________________________ Signature ______________________________________________

!! Physician !! Physician’s Assistant !! Nurse Practitioner

DATE EACH DOSE WAS GIVEN

/ /

/ /

IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)

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)

_________________________________________ . This Child Care Center/School provides a program which extends from _____ : ____(NAME OF CHILD CARE CENTER/SCHOOL)

a.m./p.m. to ______ a.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 thisreport 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:

LIC 701 (8/08) (Confidential)

1st 2nd 3rd 4th 5thVACCINE

POLIO (OPV OR IPV)

DTP/DTaP/DT/Td

MMR

HIB MENINGITIS

HEPATITIS B

VARICELLA

(DIPHTHERIA, TETANUS AND[ACELLULAR] PERTUSSIS OR TETANUSAND DIPHTHERIA ONLY)

(MEASLES, MUMPS, AND RUBELLA)

(REQUIRED FOR CHILD CARE ONLY)

(CHICKENPOX)

(HAEMOPHILUS B)

/ / / / / / / / / /

/ / / / / / / / / // / / // / / / / /

/ / / // / / /

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.

STATE OF CALIFORNIAHEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING

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 innursing 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

DAILY ROUTINES (*For infants and preschool-age children only)

DEVELOPMENTAL HISTORY (*For infants and preschool-age children only)

STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY

CHILD’S NAME SEX BIRTH DATE

DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

DATE OF LAST PHYSICAL/MEDICAL EXAMINATION

FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME

MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME

IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?

BEGAN TALKING AT*MONTHS

TOILET TRAINING STARTED AT*MONTHS

WALKED AT*MONTHS

SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS

DOES CHILD HAVE FREQUENT COLDS? !! YES !! NO

WHAT TIME DOES CHILD GET UP?*

DOES CHILD SLEEP DURING THE DAY?*

DIET PATTERN:(What does child usuallyeat for these meals?)

ANY FOOD DISLIKES?

WORD USED FOR “BOWEL MOVEMENT”*PARENT’S EVALUATION OF CHILD’S HEALTH

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 DATE

LIC 702 (8/08) (CONFIDENTIAL)

WORD USED FOR URINATION*

IS CHILD TOILET TRAINED?*!! YES !! NO

IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?

!! YES !! NO

IF YES, NAME OF DOCTOR: DOES CHILD TAKE PRESCRIBED MEDICATION(S)?

!! YES !! NO

IF YES, WHAT KIND AND ANY SIDE EFFECTS:

IF YES, AT WHAT STAGE:* ARE BOWEL MOVEMENTS REGULAR?*!! YES !! NO

ANY EATING PROBLEMS?

WHAT IS USUAL TIME?*

BREAKFAST

LUNCH

DINNER

WHEN?* HOW LONG?*

WHAT ARE USUAL EATING HOURS?

BREAKFAST ________________________

LUNCH_____________________________

DINNER

WHAT TIME DOES CHILD GO TO BED?* DOES CHILD SLEEP WELL?*

HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF

PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:DATES

!! Chicken Pox

!! Asthma

!! Rheumatic Fever

!! Hay Fever

!! Diabetes

!! Epilepsy

!! Whooping cough

!! Mumps

!! Poliomyelitis

!! Ten-Day Measles(Rubeola)

!! Three-Day Measles(Rubella)

DATES DATES

CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING

DOES CHILD USE ANY SPECIAL DEVICE(S):

!! YES !! NO

DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?

!! YES !! NO

IF YES, WHAT KIND: IF YES, WHAT KIND:

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING DIVISION

CHILD CARE CENTERNOTIFICATION OF PARENTS’ RIGHTS

PARENTS’ RIGHTSAs 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 filekept by the licensing office.

3. Review, at the child care center, reports of licensing visits and substantiated complaints against thelicensee made during the last three years.

4. Complain to the licensing office and inspect the child care center without discrimination or retaliationagainst you or your child.

5. Request in writing that a parent not be allowed to visit your child or take your child from the childcare 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: _________________________________________________

Licensing Office Address: _________________________________________________

Licensing Office Telephone #: _________________________________________________

7. Be informed by the licensee, upon request, of the name and type of association to the child carecenter for any adult who has been granted a criminal record exemption, and that the name of theperson 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 APARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVEPOSES A RISK TO CHILDREN IN CARE.

LIC 995 (9/08) (Detach Here - Give Upper Portion to Parents)

AC K N OW L E D G E M E N T O F N OT 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 ________________________________________________, havereceived a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and theCAREGIVER BACKGROUND CHECK PROCESS form from the licensee.

_____________________________________Name of Child Care Center

______________________________________________ __________________Signature (Parent/Authorized Representative) Date

NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given toparent/authorized representative.

LIC 995 (9/08)

For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov

For the Department of Justice “Registered Sex Offender”database go to www.meganslaw.ca.gov

FORM SPI CACFP 1269E/IEA (Rev. 6/09) Page 1 OSPI/Child Nutrition Services Attachment 2 to Bulletin No. 028-10 CNS June 30, 2010

Child and Adult Care Food Program ENROLLMENT/INCOME-ELIGIBILITY APPLICATION

PART 1 - CHILDREN’S INFORMATION

Child’s Name Birthdate Age Circle Normal Days/

Print Normal Hours of Care Circle

Meals Normally Received

Sun Mon Tu Wed Th Fri Sat Normal Hours to

Breakfast A.M. Snack Lunch P.M. Snack Supper Eve. Snack

Sun Mon Tu Wed Th Fri Sat Normal Hours to

Breakfast A.M. Snack Lunch P.M. Snack Supper Eve. Snack

Sun Mon Tu Wed Th Fri Sat Normal Hours to

Breakfast A.M. Snack Lunch P.M. Snack Supper Eve. Snack

INCOME ELIGIBILITY

Please check one box: My child(ren) receive(s) benefits from Washington Basic Food (WBF), TANF, or FDPIR. (Please complete Part 2 and 5.)

This child is a foster child. (Please complete Part 3 and 5.) One form per foster child.

My child(ren) may qualify for Free/Reduced-Price meals based on household income. (Please complete Part 4 and 5.)

My child(ren) will not qualify for Free/Reduced-Price meals. (Please complete Part 5 only.) PART 2 - CHILDREN RECEIVING WASHINGTON BASIC FOOD (WBF), TANF, OR FDPIR

Child’s Name Circle One Case Number or Identification Number

WBF TANF FDPIR

WBF TANF FDPIR

WBF TANF FDPIR

PART 3 - FOSTER CHILD—One form per foster child Child’s Name Child’s Personal Use Monthly Income (if None, Write “0”)

PART 4 - TOTAL HOUSEHOLD INCOME FROM LAST MONTH—Not Required if You Have Reported a Case Number in Part 2

List Names (First and Last) of Everyone in Your Household

Gross Income from Last Month (if None, Write “0”)Earnings from Work Before Deductions

Alimony, Child Support,

Welfare

Retirement, Pensions,

Social Security

Job Two or Any Other

Income 1.

2.

3.

4.

5.

6.

7.

PART 5 - SIGNATURE AND CERTIFICATION The adult household member who fills out the application must sign below. If Part 4 is completed, the adult signing the form must also list his/her Social Security Number or check the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page.) If you have listed a case number in Part 2 or are applying for a foster child, or have checked the box that your child(ren) will not qualify for Free/Reduced-Price meals, a Social Security number is not needed. I certify that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds; that institution officials may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. Signature of Adult Date

Print Name of Adult Signing

I do not have a Social Security Number

Social Security Number

ADDRESS CITY/STATE/ZIP CODE

DAYTIME PHONE

FORM SPI CACFP 1269E/IEA (Rev. 6/09) Page 2 OSPI/Child Nutrition Services Attachment 2 to Bulletin No. 028-10 CNS June 30, 2010

PART 6 – IDENTIFYING INFORMATION AND CERTIFICATION OF DATA—You Are Not Required to Answer This Part. Check the ethnic and racial category of your child. We need this information to be sure that everyone receives benefits on a fair basis. Ethnicity: Hispanic or Latino No child will be discriminated against because of race, Not Hispanic or Latino color, national origin, gender, age, or disability. Race: White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Pacific Islander Multi-Racial If you feel you have been discriminated against, you should write USDA, Director of Civil Rights, 1400 Independence Avenue SW, Washington, DC 20250-9410.

PRIVACY ACT STATEMENT

The Richard B. Russell National School Lunch Act requires that, unless the participant’s WBF, TANF, or FDPIR case number is provided, you must include the social security number of the adult household member signing the application, or indicate that the household member does not have a social security number. Provision of a social security number is not mandatory, but if a social security number is not provided or an indication is not made that the signer does not have a social security number, the application cannot be approved. This notice must be brought to the attention of the household member whose social security number is disclosed. The social security number may be used to identify the household member in carrying out efforts to verify the correctness of information stated on the application. These verification efforts may be carried out through program reviews, audits, and investigations and may include contacting employers to determine income, contacting a WBF or welfare office to determine current certification for receipt of WBF or TANF benefits, contacting the state employment security office to determine the amount of benefits received, and checking the documentation produced by the household member to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims, or legal actions if incorrect information is reported.

CENTER USE ONLY Check one: Free Category Reduced-Price Category Above-Scale Category Total Monthly Income $ This form must be signed and dated by the institution’s authorized representative. SIGNATURE OF INSTITUTION’S AUTHORIZED REPRESENTATIVE DATE

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

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)

TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE

STATE OF CALIFORNIAHEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING DIVISION

IDENTIFICATION AND EMERGENCY INFORMATIONCHILD CARE CENTERS/FAMILY CHILD CARE HOMESTo Be Completed by Parent or Authorized RepresentativeCHILD’S NAME LAST MIDDLE FIRST

ADDRESS NUMBER STREET CITY STATE ZIP

FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST

HOME ADDRESS NUMBER STREET CITY STATE ZIP

MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST

HOME ADDRESS NUMBER STREET CITY STATE ZIP

PERSON RESPONSIBLE FOR CHILD LAST NAME MIDDLE FIRST

PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER

DENTIST ADDRESS MEDICAL PLAN AND NUMBER

TIME CHILD WILL BE CALLED FOR

SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE

DATE OF ADMISSION

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

!! CALL EMERGENCY HOSPITAL !! OTHER EXPLAIN: ____________________________________________________________________________________________________________________

NAME

NAME

ADDRESS TELEPHONE RELATIONSHIP

RELATIONSHIP

SEX

HOME TELEPHONE

( )

TELEPHONE

( )

TELEPHONE

( )TELEPHONE

( )

DATE

DATE LEFT

BIRTHDATE

BUSINESS TELEPHONE

( )

BUSINESS TELEPHONE

( )

BUSINESS TELEPHONE

( )

HOME TELEPHONE

( )

HOME TELEPHONE

( )

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

LIC 700 (8/08)(CONFIDENTIAL)