KANSAS EMERGENCY INFORMATION PACKET · 2 days ago · INSTRUCTIONS KANSAS EMERGENCY INFORMATION...

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INSTRUCTIONS KANSAS EMERGENCY INFORMATION PACKET SITES WITH Y CLUB, PRE-K AND/OR PRESCHOOL PROGRAMS All of our programs are licensed by the Kansas Department of Health and Environment. This is a set of documents which is required by state law. 1. Do not return this packet to the Youth Development Services office. 2. Complete all the forms in this packet. 3. Parent/Guardian is responsible for making copies. 4. Take a copy to your child’s site. 5. Always take a copy any time your child attends a No School Day, Snow Day or Summer Day Camp. A completed copy of this packet must accompany your child at all times. YMCA staff will not transfer this file between sites. 6. Notify your site supervisor of any changes. If you have any questions about this packet, please contact your site supervisor or Youth Development Services. OUR MISSION The YMCA of Greater Kansas City, founded on Christian principles, is a charitable organization with an inclusive environment committed to enriching the quality of family, spiritual, social, mental and physical well-being. A UNITED WAY AGENCY YMCA OF GREATER KANSAS CITY YOUTH DEVELOPMENT SERVICES 8205 West 108th Terrace, Suite 120 Overland Park KS 66210 P 913.345.9622 F 913.345.0524 KansasCityYMCA.org Revised 07.2017

Transcript of KANSAS EMERGENCY INFORMATION PACKET · 2 days ago · INSTRUCTIONS KANSAS EMERGENCY INFORMATION...

Page 1: KANSAS EMERGENCY INFORMATION PACKET · 2 days ago · INSTRUCTIONS KANSAS EMERGENCY INFORMATION PACKET SITES WITH Y CLUB, PRE-K AND/OR PRESCHOOL PROGRAMS All of our programs are licensed

INSTRUCTIONS

KANSAS EMERGENCY INFORMATION PACKETSITES WITH Y CLUB, PRE-K AND/OR PRESCHOOL PROGRAMS All of our programs are licensed by the Kansas Department of Health and Environment. This is a set of documents which is required by state law.

1. Do not return this packet to the Youth Development Services office.2. Complete all the forms in this packet.3. Parent/Guardian is responsible for making copies.4. Take a copy to your child’s site.5. Always take a copy any time your child attends a No School Day,

Snow Day or Summer Day Camp. A completed copy of this packet must accompany your child at all times. YMCA staff will not transfer this file between sites.

6. Notify your site supervisor of any changes.

If you have any questions about this packet, please contact your site supervisor or Youth Development Services.

OUR MISSION The YMCA of Greater Kansas City, founded on Christian principles, is a charitable organization with an inclusive environment committed to enriching the quality of family, spiritual, social, mental and physical well-being. A UNITED WAY AGENCY

YMCA OF GREATER KANSAS CITY YOUTH DEVELOPMENT SERVICES 8205 West 108th Terrace, Suite 120 Overland Park KS 66210P 913.345.9622 F 913.345.0524

KansasCityYMCA.org

Revised 07.2017

Page 2: KANSAS EMERGENCY INFORMATION PACKET · 2 days ago · INSTRUCTIONS KANSAS EMERGENCY INFORMATION PACKET SITES WITH Y CLUB, PRE-K AND/OR PRESCHOOL PROGRAMS All of our programs are licensed

CHILD’S INFORMATION

Child’s Name ___________________________________________________________________________Sex _______________Birth Date ___________________________

Address ______________________________________________________________________________________________________________________________________________

City ______________________________________________________________________________________State ____________________ Zip ____________________________

Parent/Guardian ___________________________________________________________________________________________________________________________________

Address ______________________________________________________________________________________________________________________________________________

City ______________________________________________________________________________________State ____________________ Zip ____________________________

Home Phone _____________________________________________ Cell Phone ______________________________________ Carrier ____________________________

Work Phone _____________________________________________________________ Email Address _________________________________________________________

Employer_________________________________________________________________ Hours ___________________________________________________________________

Parent/Guardian ___________________________________________________________________________________________________________________________________

Address ______________________________________________________________________________________________________________________________________________

City ______________________________________________________________________________________State ____________________ Zip ____________________________

Home Phone _____________________________________________ Cell Phone ______________________________________ Carrier ____________________________

Work Phone _____________________________________________________________Email Address _________________________________________________________

Employer_________________________________________________________________ Hours ___________________________________________________________________

ENROLLMENT POLICIES• A Family Handbook has been received regarding YMCA Child Care policy pertaining to admission, care and discharge of

children. I understand I need to read the Family Handbook to become familiar with YMCA policies. • I give permission to receive texts.• I give permission for pictures and/or videos to be taken of my child during YMCA Child Care activities for publicity purposes.• I agree to indemnify and hold harmless the YMCA, their officials and employees affiliated with the program from and against

any and all liability for any injury, which may be suffered by my child out of or any way connected with the participation in theYMCA School Age or Early Learning programs. I agree not to hold the YMCA responsible for lost or stolen personal items.

• I UNDERSTAND AND AGREE TO THE POLICIES INDICATED ABOVE AND THE POLICIES DESCRIBED IN THE FAMILY HANDBOOK.I AM HEREBY ENROLLING MY CHILD INTO THE YMCA CHILD CARE PROGRAM, FOR THE DAYS AND HOURS INDICATED.

Parent/Guardian Signature ___________________________________________________________________________________Date ___________________________

ENROLLMENT INFORMATION (to be completed by YMCA employee):

Session(s)/Hours & Days ________________________________________________________________________________________________________________________

Admission Date ________________________________________________________Discharge Date _______________________________________________________Revised 09/16

YMCA of Greater Kansas CityFamily Information

Page 3: KANSAS EMERGENCY INFORMATION PACKET · 2 days ago · INSTRUCTIONS KANSAS EMERGENCY INFORMATION PACKET SITES WITH Y CLUB, PRE-K AND/OR PRESCHOOL PROGRAMS All of our programs are licensed

CCL. 029 Kansas Department of Health and Environment Rev. 3/2017 Bureau of Family Health Child Care Licensing Program 1000 SW Jackson, Suite 200 Topeka, KS 66612-1274 Phone (785) 296-1270 Fax (785) 559-4244 Website: www.kdheks.gov/kidsnet

MEDICAL RECORD FOR ALL CHILDREN IN CHILD CARE FACILITIES,

INCLUDING PROVIDER’S OWN CHILDREN

Parents are to complete the Medical Record and the History of Immunizations for each child in licensed child care facilities. The Medical Record, History of Immunizations, and Child Health Assessment are transferable when the child moves to another licensed child care facility.

Child’s First Day in Child Care Name of Child Care Facility

Child’s Name Date of Birth Gender First Last MM/DD/YYYY M/F

Parent/Guardian Information Parent/Guardian Information

Name Name

Home Address Home Address

Street City Zip Code Street City Zip Code

Home Phone Number Home Phone Number

Work Address Work Address

Street City Zip Code Street City Zip Code

Work Phone Number Work Phone Number

Cell Phone Number Cell Phone Number

E-mail Address E-mail Address

Best way to contact Best way to contact Names and ages of children in family

Persons authorized to pick up the child or to notify in case of emergency. Include name, address, and telephone number.

Attach an additional page, if necessary.

Child’s Physician Phone Number

Child’s Dentist Phone Number

Hospital Preference (for emergencies)

Has your physician approved the use of any non-prescription medications for your child such as acetaminophen, cough

syrup, or ointments that can be given by the child care provider? No Yes, as follows:

Does your child have any of the following conditions (yes or no)? If yes, provide information on Authorization for

Emergency Medical Care form CCL. 010. Allergies Frequent sore throats/colds Ear Aches

Asthma Speech, Visual, Hearing Diabetes Epilepsy/Seizures Other

If yes answered to any above, please provide additional information

Have there been major changes at home that might affect your child in care? No Yes, as follows:

Please provide additional information or special instructions that will help the person caring for your child.

Parent/Guardian Signature:_________________________________________Date:_____________ 1

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History of Immunizations

Required for all children in child care facilities, including the provider’s own children. A Kansas Certificate of Immunizations (KCI) may be substituted for this form and attached to the completed Medical Record.

Child’s Name: Date of Birth: First Last MM/DD/YYYY

Section I. For a recommended schedule of immunizations, refer to the current schedule published by the Advisory Committee on Immunization Practices (ACIP).

Vaccine Record the Month. Day and Year that each Dose of Vaccine was Received 1st 2nd 3rd 4th 5th 6th

Diphtheria, Tetanus, Pertussis (DTaP)

Poliomyelitis (IPV/OPV)

Measles, Mumps, Rubella (MMR)

Hepatitis B (HepB)

Varicella (VAR) Hx of Disease: Date of Illness: Physician Signature

Hemophilus Influenzae Type B (Hib)

Pneumococcal Conjugate (PCV)

Hepatitis A (HepA)

Rotavirus **Recommended <8 mo of age; not required

Influenza(Flu) ** Recommended annually >6 mo of age; not required

Section II. Complete this section only if your child is exempted from the law requiring immunizations [K.S.A. 65-508(d)].

Section II. Complete Section below only if your child is exempted from laws requiring requiring immunizations [ K.S.A. 65-508(d) and K.S.A. 65-519(c) ]

Section III.

2

The following two options are the ONLY exemptions allowed by law. Please check either (A) or (B) below and complete as required:

(A) Certification from licensed physician stating that immunization would endanger child’s life:

Exempt from following immunizations:

DTaP/DT _____Tdap/TD Pertussis Only ____Polio MMR HepA HepB Hib

_____PCV ____Varicella ___Other

Physician’s Signature (required): ________________________________________________Date:_______________

(B) My child is exempt under the law from immunizations. As the Parent or Legal Guardian, I state that I am an adherent of a religious denomination whose teachings are opposed to immunizations.

Parent/Guardian Signature:_________________________________________Date:________________

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CCL. 029a Rev. 3/2017

Child Health Assessment

The Child Health Assessment form is to be completed and signed by a nurse approved by KDHE to perform Child Health Assessments or a Licensed Physician. If a Physician Assistant (PA) completes the Child Health Assessment, the signature

of the Licensed Physician authorizing the PA is to be included at the bottom of this form.

A Child Health Assessment, recorded on a KDHE Form or other acceptable Forms mentioned below, is required for all children including children of the provider or staff in Licensed Day Care Homes, Group Day Care Homes, Child Care

Centers and Preschools. A Kan-Be-Healthy Assessment Form is a KDHE Form and is acceptable, a Physician Health Assessment Form is acceptable, and a School Health Assessment Form is acceptable for school-age children or youth.

The Health Assessment Form used should be attached to the KDHE Medical Record Form (CCL. 029).

Child’s Name_________________________________________ Date of Birth___________________

First Last

Health history and medical information pertinent to routine child care and emergencies (describe, if any): None

Do you see this child for regular health supervision: Yes No

Allergies to food or medicine (describe, if any):

None

List current medications (if any):

None

Length/Height: ______IN/CM %ILE_______

Weight: _____LB/KB %ILE_______

Physical Examination If Normal If Abnormal - Comments

Head/Ears/Eyes/Nose/Throat

Teeth

Cardio/Respiratory

Abdomen/GI

Genitalia/Breasts

Extremities/Joints/Back/Chest

Skin/Lymph Nodes

Neurologic & Developmental

Screening Tests Screening Date Note Here if Results are Pending or Abnormal

Lead

Anemia (HGB/HCT)

Urinalysis (UA)

Hearing

Vision

Health Problems or Special Needs, Recommended Treatment/Medications/Special Care (Attach additional sheets if necessary)

None

Signature of Licensed Physician or Nurse approved for Child Health Assessments

Date

Print the Name of the Individual Signing Above

Phone Number

Address City Zip Code

3

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CCL 010 Kansas Department of Health and Environment Rev. 3/2017 Bureau of Family Health 1000 SW Jackson, Suite 200 Topeka, KS 66612-1274 Child Care Program: (785) 296 -1270 Fax: (785) 559-4244 Website: www.kdheks.gov/kidsnet

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

Written permission for emergency medical treatment must be on file at the facility. Consult with the local emergency medical facility to be sure this form is acceptable. Reference K.A.R. 28-4-127(b)(1)(A). School Age Programs reference K.A.R. 28-4-582(e)(2).

Name of facility exactly as stated on the license.

License #

I hereby authorize _________________________________________________________ (Name of individual/staff member) and/or ____________________________________________________ (Name of individual/staff member) who is (are) representative(s) of the above named facility to give consent for any and all necessary emergency medical care for my child or youth _____________________ ___________________________________________ (First and Last Name of Child or Youth) while said child or youth is in said facility’s custody between the dates of ___________________________ and ____________________________. MM/DD/YYYY MM/DD/YYYY

Signature of Parent or Guardian Date Signed

Witness to Parent’s or Guardian’s signature if required by the local hospital or clinic. Date Signed

Notarization of Parent’s or Guardian’s signature if required by local hospital or clinic.

State of Kansas County of ________________________

Signed or attested before me on ____________________ by______________________________________________.

MM/DD/YYYY Name of Person

(Seal, if any.)

_______________________________________________

Signature of notarial officer

______________________________________________

Title (and Rank)

My appointment expires: __________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

List any known allergies or other information about the medical status of this child or youth pertinent in case of emergency:

Is child covered by health insurance? Yes No

If yes, complete the following:

Health Insurance Policy Name _________________________________________ Policy Number ______________________

Medical Assistance Program ____________________________________________ Card Number________________________

Military Medical Care I.D. Number ___________________________________________________________________________

If known, date of last Tetanus inoculation: __________________________________

THE MEDICAL RECORD/ASSESSMENT FORM (OR HEALTH STATUS HISTORY FORM FOR SCHOOL AGE PROGRAMS) AND THE AUTHORIZATION FOR EMERGENCY MEDICAL CARE MUST BE TAKEN TO THE EMERGENCY ROOM. BOTH FORMS MUST ALSO BE IN A VEHICLE WHEN THE CHILD OR YOUTH IS TRANSPORTED BY THE FACILITY.

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YMCA of Greater Kansas CityEmergency/Authorization Information

EMERGENCY INFORMATION/AUTHORIZATION FOR PICKUP Person(s) authorized to take child from YMCA program facility (other than parent or doctor). Provide a minimum of three contacts:

Name ____________________________________________________________________________________Relationship ____________________________________________

Address ______________________________________________________________________________________________________________________________________________

City ______________________________________________________________________________________State ____________________ Zip ____________________________

Home Phone _____________________________________ Cell Phone ____________________________________Work Phone _______________________________

Name ____________________________________________________________________________________Relationship ____________________________________________

Address ______________________________________________________________________________________________________________________________________________

City ______________________________________________________________________________________State ____________________ Zip ____________________________

Home Phone _____________________________________ Cell Phone ____________________________________Work Phone _______________________________

Name ____________________________________________________________________________________Relationship ____________________________________________

Address ______________________________________________________________________________________________________________________________________________

City ______________________________________________________________________________________State ____________________ Zip ____________________________

Home Phone _____________________________________ Cell Phone ____________________________________Work Phone _______________________________

Name ____________________________________________________________________________________Relationship ____________________________________________

Address ______________________________________________________________________________________________________________________________________________

City ______________________________________________________________________________________State ____________________ Zip ____________________________

Home Phone _____________________________________ Cell Phone ____________________________________Work Phone _______________________________

Parent/Guardian Signature ___________________________________________________________________________________ Date __________________________ Revised 03/15

Page 8: KANSAS EMERGENCY INFORMATION PACKET · 2 days ago · INSTRUCTIONS KANSAS EMERGENCY INFORMATION PACKET SITES WITH Y CLUB, PRE-K AND/OR PRESCHOOL PROGRAMS All of our programs are licensed

Child’s Name _______________________________________________________________________Date of Birth _______________________________

I authorize the exchange of current and prior school records, educational, medical, psychological, physical therapy, occupational therapy, speech therapy or behavior information regarding my child between the YMCA Early Learning Center and the parties/agencies listed below. A photocopy of the authorization shall be considered valid. I understand that my child’s records are protected by Federal Law and cannot be disclosed without written consent unless otherwise provided by law. I also understand that I may revoke consent in writing at any time except to the extent that records may already have been requested or received.

Parent/Guardian Signature ______________________________________________________________________________________________________

Address ______________________________________________________________________________________________________________________________

City ____________________________________________________________________________________________State ________________________________

Home Phone ________________________________________________________________________________________________________________________

Work Phone _________________________________________________________________________________________________________________________

Mobile Phone _______________________________________________________________________________________________________________________

Center ________________________________________________________________________________________________________________________________

Address ______________________________________________________________________________________________________________________________

City ____________________________________________________________________________________________State ________________________________

Phone __________________________________________________________________Fax _________________________________________________________

Contact ______________________________________________________________________________________________________________________________

Agency/Person _____________________________________________________________________________________________________________________

Address ______________________________________________________________________________________________________________________________

City ____________________________________________________________________________________________State ________________________________

Phone __________________________________________________________________Fax _________________________________________________________

Contact ______________________________________________________________________________________________________________________________

There are no prior records or documents that will assist the YMCA in offering services for my child.

Parent Signature ____________________________________________________________________________Date ________________________________ Revised 01/15

YMCA of Greater Kansas CityExchange of Information

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Child’s Name _______________________________________________________________________Date ________________________________

Date of Birth _______________________________________________________________________ Sex: F ____________M _______________

Guardian _________________________________________________________________ Relationship _________________________________

1. What language(s) is/are spoken in your home? English Other_______________________________

2. How much of the day is English spoken?All of the time Some Not Often

3. Please list the names and relationships of family members that are special to your child(e.g. sister, brother, grandma, auntie, etc.) ____________________________________________________________ __________________________________________________________ ____________________________________________________________ __________________________________________________________ ____________________________________________________________ __________________________________________________________ ____________________________________________________________ __________________________________________________________

4. Please share about your family traditions, including home language, culture, family structure,religion, race, etc. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Please share your thoughts on your family rearing practices that would assist the center.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Has your child previously been in a child care program? Yes No

7. Does your child have an IEP or Behavior Plan? Yes NoIf yes, please describe. _____________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Does your child make friends easily? Yes No

9. Which best describes your child’s overall personality?Shy Quiet OutgoingComments ____________________________________________________________________________________________________________

10. In What areas could staff aid in your child’s development?Independence Mental Response CriticismDependability Physical Condition SharingTemperament Patience

11. Is your child taking medication on a daily basis? Yes NoIf yes, please list medication and reason for prescription __________________________________________________________________________________________________________________________

12. Has your child ever been diagnosed as having Allergies, ADHD, or any type of “Special Need” disorder? Yes NoIf yes, please describe _____________________________________________________________________________________________ __________________________________________________________________________________________________________________________

13. Does your child have a dentist? Yes NoDentist’s name ______________________________________________________________________________________________________

YMCA of Greater Kansas CityChild Questionnaire

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Child’s Name _________________________________________________________________________________________________________

14. In what way does your child communicate? __________Gestures (points to desired object)

__________Single words __________Puts two or more words together __________Follows direction __________Answers questions

15. How well does your child understand what is said to him/her?

__________Clearly understands everything said to him/her __________Understands simple statements and commands __________Understands what is said when speaker gestures __________Understands very little of what is said to him/her

16 Does your child point to pictures you name in a book? Yes No

17. If your child has favorite books, please list. ____________________________________________________________________________________________________________________________________________________________________________________________

18. What activities does your child enjoy doing? Please describe. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

19. Does your child eat most foods offered? Yes No

20. Does your child avoid any foods? Please list. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

21. Does your child dislike or crave foods that are any of these textures or tastes: spicy, crunchy,hot, cold, sweet, mushy? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

22. Doesyourchildhavedifficultychewingorswallowinganyfoods?Yes No

23. Does your child enjoy tooth brushing? Yes No

24. Whatarethreespecificgoalsforyourchild’seducation? ________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________

25. How can we support your family’s involvement in our program? _______________________________________ __________________________________________________________________________________________________________________________

26. Would you be willing to work together with us in carrying over new skills at home?Yes No

27. Will you take responsibility to read the daily notes/journal that are written by his/her teachers and write us back your thoughts, comments or questions? Yes No

28. Please list any additional comments or information you would like to give about your child or family. _________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________

Thank You! Revised 09/16

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Page 12: KANSAS EMERGENCY INFORMATION PACKET · 2 days ago · INSTRUCTIONS KANSAS EMERGENCY INFORMATION PACKET SITES WITH Y CLUB, PRE-K AND/OR PRESCHOOL PROGRAMS All of our programs are licensed

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