Thrivalaska’s School Age Program at Midnight Sun Enrollment ApplicationTHIS APPLICATION MUST BE COMPLETED IN FULL.Questions? Contact Smensch2@thrivalaska.com Today's Date * MM DD YYYY Child's Full Name * First Name Last Name Child's Sex * Male Female Child's Date of Birth * MM DD YYYY Nickname(s): Guardian One: Name * First Name Last Name Relationship: * Social Security #: * Driver's License #: * Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Physical Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone * (###) ### #### Occupation: * Employer: * Work Phone: * (###) ### #### Fax: Cell Phone/ Pager: * (###) ### #### Email * Guardian Two: Name First Name Last Name Relationship: Social Security #: Driver's License #: Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Physical Address Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Occupation: Employer: Work Phone (###) ### #### Fax: Cell Phone/ Pager: (###) ### #### Email Please describe who the child lives with: * Other siblings enrolled in this Thrivalaska Program: Other siblings enrolled in a different Thrivalaska Program: Pick Up Authority: Who is authorized to pick up your child? * Who is restricted from picking up your child? (Please send custody or court orders to smensch2@thrivalaska.com if relevant) Health: Are there any previous or current medical conditions we should be aware of? If yes, please explain. * Are there any health conditions such as seasonal allergies or eczema, that may be experienced by the child, but don’t always occur? If yes, please explain. * Does your child have any allergies? * Yes No Unknown at this time If yes, please list them: If your child does have an allergic reaction, what does it look like? If your child does have an allergic reaction, what steps need to be taken? Do you have any concerns about your child’s hearing, vision, or speech? If so, what are they? Is your child currently taking medication? What is it and what is it prescribed for? * Does your child need any special attention in any of the following areas? Please be specific as to what assistance your child needs: Activity Level Behavior Management Feeding or Special Diet Physical Resting/ Sleep Toileting Please describe the areas of assistance indicated above: Development: (Please be candid, this information is to help us best meet your child's needs. Your responses will NOT affect enrollment) Please base this on your child's age. Is your child average, above average, or needs improvement in relationship to other children the same age: Ability to express needs * Needs Improvement Average Above Average Ability to express his/her thoughts & ideas * Needs Improvement Average Above Average Accepting guidance from adults * Needs Improvement Average Above Average Controlling temper, appropriate outlets for anger * Needs Improvement Average Above Average Cleaning up after his/herself * Needs Improvement Average Above Average Following directions from adults * Needs Improvement Average Above Average Helping others, children &/or adults * Needs Improvement Average Above Average Making friends * Needs Improvement Average Above Average Playing independently, finding own activities * Needs Improvement Average Above Average Playing safely, both for self & others * Needs Improvement Average Above Average Solving own problems appropriately * Needs Improvement Average Above Average Temperament Assessment: Please answer the following questions so we can establish an understanding of your child’s temperament, which is an important step in providing nurturing and supportive care. Children and adults have temperamental tendencies that affect the ways in which we they think, behave, and respond to people and events. Temperamental differences are determined by heredity. Activity Level- How much does your child wiggle and move around when being read to, sitting at a table or playing alone? * Active 1 3 5 Quiet Regularity- Is your child regular about eating times, sleeping times, amount of sleep needed and bowel movements? * Regular 1 3 5 Irregular Adaptability- How quickly does your child adapt to changes in his/her schedule or routine? How quickly does your child adapt to new foods and places? * Adapts Quickly 1 3 5 Adapts Slowly Approach/Withdrawal- How does your child usually react the first time to new people, new foods, new toys and new activities? * Initial Approach 1 3 5 Initial Withdrawal Physical Sensitivity- How aware is your child of slight noises, slight differences in temperature, differences in taste, and differences in clothing? * Not Sensitive 1 3 5 Very Sensitive Intensity of Reaction- How strong or extreme are your child’s reactions? Does your child laugh and cry energetically, or does he/she just smile and fuss mildly? * High Intensity 1 3 5 Mild Reaction Distractibility- Is your child easily distracted, or does he/she ignore distractions? Will your child continue to work or play when other noises or children are present? * Very Distractible 1 3 5 Not Distractible Positive or Negative Mood- How much of the time does your child show pleasant, joyful behavior compared with unpleasant crying and fussing behavior? * Positive Mood 1 3 5 Negative Mood Persistence- How long does your child continue with one activity? Does your child usually continue if it is difficult? * Long Attention Span 1 3 5 Short Attention Span Family: It is our goal to partner with parents to provide care and education in a way that compliments each family we serve. Through family culture, children gain a sense of who they are, a feeling of belonging, what is important, what is right and wrong, how to care for themselves and others, and what to celebrate, eat and wear. Please share information about your family that will assist us in providing sensitive, responsive care for your child. 1. Please write a paragraph describing your child: * 2. What type of guidance do you find most successful with your child? * 3. What language is spoken in your home? * 4. What are your child’s favorite activities? * 5. Does your child have any fears we should be aware of? * 6. Who are the other people important in your child’s life, such as babysitter, grandparents, friends, etc.? * 7. What person or programs have cared for your child until now? * 8. Describe your family culture such as: family traditions, celebrations and holidays, mealtimes, special foods, routines, religion, ethnic background, health practices, clothing, etc. * 9. What special interests, resources or abilities can you share with us? * 10. Is there anything else about your family you would like to share with us? * Plan of Care for a Child’s Individual Needs: Thrivalaska recognizes that all children have individual needs. Some children may have a diagnosed special need and all children may have an individual need at a particular time in their life such as a broken bone, family moving, a new sibling, impending divorce, or an emotional need arising from the loss of a loved one. We strive to meet the individual needs of all children whether it is from a long term diagnosis or a short term special situation. Please fill out the following information to help us best meet individual needs. This form should be updated every 3 months when a diagnosed special need is specified and may be used whenever a new situation arises. This Plan of Care is a team effort between parents/guardians, the program director and the caregiver working directly with the child. The parent may fill out the form in advance but will need to meet with staff in order to implement the plan. My child has an individual need requiring attention at this time: * Yes No If your child has an individual need, please complete the following. Otherwise skip to "Photograph/Video Release." Child's Name: First Name Last Name Age: 1. What is your child’s individual need? 2. Does your child have a medical diagnosis? If yes, what is it? 3. If your child has a diagnosis, and has an IFSP or IEP, Child Care Licensing requires that we have a copy. Have you provided a copy to Thrivalaska? If not, please explain. 4. Have other evaluations been completed that may assist us in caring for your child? Please describe or send to smensch2@thrivalaska.com after submitting this form. 5. What additional services does the child receive and what specialists are working with your child? Occupational Therapy Physical Therapy Speech Therapy Play Therapy Mental Health Educational Therapy Other* *If other, explain below: 6a. What, if any, of these services need to be accommodated at Thrivalaska, such as time and space for a physical therapist? 6b. Do any of the plans from other professionals have pieces that need to be implemented by Thrivalaska? If so, what are they and how will they be implemented? 7. What priorities, needs and/or concerns are there for your family? 8. What is the child’s present cognitive or overall functional level and skills: 9. What emergency or unusual circumstance might arise from this special situation? 10. If your child’s individual need at this time involves behavior issues that put your child, other children, or the staff at risk, what is the agreed upon plan of action that will keep all safe? 11. Will your child need special accommodations from Thrivalaska to meet their needs? Such as a proper height chair, wheel chair accessibility, need to call mom when upset, elevation for a broken leg, etc. If so, please describe: 12a. Are there any specific services needed from Thrivalaska to meet functional outcome objectives? 12b. Coordinating this service is the responsibility of: 12c. Paying for this service is the responsibility of: 13. Will your child need special routine care such during eating, resting, toileting, diapering? If so, please describe: 14. Is your child taking medication? What is it and what is it prescribed for? Are there possible side effects we should be aware of? 15. Are any special emergency and or medical procedures required: 16. Does the Thrivalaska staff need any special training to provide care to your child? If so, please describe what it is and who will provide it: 17. How much does your child understand about the situation? 18. Please choose yes once for A, B, or C: A) This information must remain confidential between the 3 listed below.* Yes No B) This information may be shared on a “need to know” basis including staff, classroom teachers and substitutes.* Yes No *For A & B, the “need to know” basis is to be determined by the 3 signers below. Please list who is responsible for sharing the information and how it will be shared: C) This information is not confidential and may be known to others, including other children and families. Yes No This Plan of care for: First Name Last Name has been discussed between parent(s)/guardian(s), Thrivalaska director, and the child’s direct caregiver, and agreed upon for the child’s admission in the program. Photograph/Video Release: I give Thrivalaska permission to use my child’s photograph for advertisement purposes, in newsletters, brochures, etc. * Yes No Enews: I am interested in receiving the Thrivalaska bi-monthly enewsletter. Please send it to the following email address: Field Trip Permission: My child has permission to go on any fieldtrips made in conjunction with the Thrivalaska School Age program. * Yes No Sunscreen/Insect Repellent Permission: I give Thrivalaska staff permission to apply insect repellent and sunscreen when necessary. I will not send bottles of sunscreen or insect repellent with my child or in their backpack. Sunscreen * Yes No Insect Repellent * Yes No Child's Name: * First Name Last Name Date * MM DD YYYY Name of guardian that filled out this form: * First Name Last Name * I acknowledge that submitting this form serves as an electronic signature Thank you!
