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