FOR OFFICE USE ONLY: TEANECK RECREATION DEPARTMENT ... · After School Application 2015-2016...
Transcript of FOR OFFICE USE ONLY: TEANECK RECREATION DEPARTMENT ... · After School Application 2015-2016...
TEANECK RECREATION DEPARTMENT
AFTER SCHOOL CHILD CARE PROGRAM
SEPTEMBER 4, 2015 - JUNE 23, 2016
(PLEASE PRINT) APPLICATION FORM
Date ___________
Application fee non-refundable
NAME ___________________________________________________________________________
LAST FIRST MIDDLE INITIAL
NICKNAME ______________________________________________ SEX _____________________
ADDRESS__________________________________________________________________________
TELEPHONE__________________________ BIRTH DATE ______________ AGE _________
FATHER CELL # ______________________ MOTHER CELL #_____________________________
SCHOOL ____________________________ GRADE AS OF SEPTEMBER 2014______________
EMAIL CONTACT __________________________________________________________________
***********************************************************************************
FATHER’S NAME ________________________________________________________________
EMPLOYER NAME & ADDRESS ____________________________________________________
HOURS OF WORK _____________________ BUSINESS PHONE _________________________
***********************************************************************************
MOTHER’S NAME ________________________________________________________________
EMPLOYER NAME & ADDRESS ___________________________________________________
HOURS OF WORK _____________________ BUSINESS PHONE ________________________
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FOR OFFICE USE ONLY:
Enrollment
Date: ________________
Proof of Residency _____
Birth Certificate _______
Application Fee _______
Doctor’s Note _________
Proof of Health Ins._____
First Payment _________
APPLICATION FORM PAGE 3 TEANECK RECREATION DEPARTMENT
Child’s Name___________________________
PARENTAL AUTHORIZATION FOR EMERGENCY TREATMENT
LIST ANY MEDICAL RESTRICTIONS AND/OR ALLERGIES: __________________________________
_______________________________________________________________________________________
IN CASE OF EMERGENCY, PLEASE INDICATE NAME AND PHONE NUMBER OF PERSON TO BE
CONTACTED IF PARENT CANNOT BE REACHED:________________________________________
_______________________________________________________________________________________
NAME OF FAMILY PHYSICIAN ___________________________________________________________
ADDRESS OF FAMILY PHYSICIAN __________________________ PHONE NUMBER _________________
PARENT’S SIGNATURE: ______________________________DATE _________________________
*******************************************************************************************
CHILD HEALTH INSURANCE: Company/HMO
Group Number ____________________________Identification # _______________________
I (we) state that we are the parent(s)/guardian(s) having legal custody of the above child and attest that
the information above is correct. I (we) authorized the above child care center director or director’s
designee to obtain emergency treatment for my child. I consent to an x-ray examination, anesthetic,
medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor at a recognized
medical facility under the general or special supervision of licensed physician or surgeon.
The following steps will be followed in an emergency:
1. The parent/guardian will be contacted immediately.
2. The child’s physician will be contacted.
3. We will attempt to contact you through all the emergency persons listed on the child’s application
form.
4. If we cannot contact you or your child’s physician, we will do any or all of the following:
(a) Call for emergency first aid assistance/transportation.
(b) Call another physician.
(c) Have the child transported to an emergency hospital in the company of a staff
PARENT’S SIGNATURE _______________________________DATE ____________________________
*******************************************************************************************
I, the undersigned agree to hold the Township Of Teaneck harmless for any accident, incident,
injury or loss of personal property that may occur as a result of my child’s participation in this
program. With this knowledge, I agree that I will not seek any claims for injury or liability
against the Teaneck Recreation Department and/or the Township.
PARENT’S SIGNATURE _______________________________DATE ____________________________
After School Application 2015-2016 Teaneck Recreation Department
TOWNSHIP OF TEANECK
TEANECK RECREATION DEPARTMENT
AFTER SCHOOL CHILD CARE PROGRAM
This serves as a contract between the Teaneck Recreation Department and parent/guardian of
__________________________________ enrolled in the After School Child Care Program.
Child’s Name
I am in receipt of the program dates, guidelines, parent information, and schedule of payment.
I fully understand that the program will end on Tuesday, June 23, 2015. I further understand
that my child/children are to adhere to the specified guidelines of the program and that if timely
payments including incurred monthly late fees, are not received as indicated on the payment
schedule my child/children’s enrollment will be suspended and/or expelled from this program.
I have been informed that employees are not permitted to accept any compensation nor tokens
of appreciation as this would be a breech in the code of ethics.
______________________________ _______________________________
Parent/Guardian’s Signature Date Lisa Skulnik
Assistant Superintendent of Recreation
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After School Application 2015-2016 Teaneck Recreation Department
INFORMATION TO PARENTS
Under provisions of the Manual of Requirements for Child Care Centers (N.J. A.C. 10:22) every
licensed child care center in New Jersey must provide to parents of enrolled children written
information on parent visitation rights, state licensing requirements, child abuse/neglect reporting
requirements and other child care matters. The center may comply with this requirement: 1) by
reproducing and distributing to parents this written statement, prepared by the Bureau of Licensing in
the Division of Youth and Family Services (DYFS); or 2) by incorporating the required information
in it’s own handbooks, brochures or other informational materials. In keeping with this requirement,
the center must secure every parent’s signature attesting to his/her receipt of the information.
***
Our center is required by the State Child Care Center Licensing Law to be licensed by the Bureau of
Licensing of the New Jersey Division of Youth and Family Services. A copy of our current license
must be posted in prominent location at our center. Look for it when you’re in the center.
To be licensed, our center must comply with the Manual of Requirements for Child Care Centers (the
official licensing regulations). The regulations cover such areas as: physical environment/life safety;
the staff qualifications, supervision, and staff/child ratios; program activities and equipment; health,
food and nutrition; rest and sleep requirements; parent/community participation; administrative and
record keeping requirements; and others.
Our center must have on the premises a copy of the Manual of Requirements for Child Care Centers
and make it available to interested parents for review. If you would like to review our copy, just ask
any staff member. Parents may secure a copy of the Manual Requirements for Child Care Centers,
by sending a check or money order for $5.00 made payable to the “Treasurer, State of New Jersey”,
and mailing it to: State of New Jersey, Department of Human Services, Licensing, Publication Fees,
P.O. Box 18500, Newark, New Jersey 07191.
We encourage parents to discuss with us any questions or concerns about the policies and program of
the center or the meaning, application or alleged violations of the Manual of Requirements for Child
Care Centers. We will be happy to arrange a convenient opportunity for you to review and discuss
these matters with us. If you suspect our center may be in violation of licensing standards, you are
entitled to report them to the Bureau of Licensing toll-free at 1-609-292-1021 or 609-292-9220. Of
course, we would appreciate your bringing these concerns to our attention, too.
Our center must have a policy concerning the release of children to parents or people authorized by
the parents to be responsible for the child. Please discuss with us your plans for your child’s
departure from the center.
Our center must have a policy about administering medicine and health care procedures and the
management of communicable diseases. Please talk to us about these policies so we can work
together to keep our children healthy.
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After School Application 2015-2016 Teaneck Recreation Department
Information to Parents (page 2)
Our center must have a policy concerning the expulsion of children from enrollment at the center.
Please review this policy so we can work together to keep your child in our center.
Parents are entitled to review the center’s copy of the Bureau of Licensing’s Inspection/Violation Reports
on the center, which are issued after every State licensing inspection of our center. If there is a licensing
complaint investigation, you are also entitled to review the Bureau’s Complaint Investigation Summary
Report, as well as any letters of enforcement of other actions taken against the center during the current
licensing period. Let us know if you wish to review them and we will make them available for your
review.
Our center must cooperate with all DYFS inspection/investigations. DYFS Staff may interview both
staff members and children.
Our center must post its written statement of philosophy on child discipline in a prominent location and
make a copy of it available to parents upon request. We encourage you to review it and to discuss with
us any questions you may have about it.
Our center must post a listing or diagram of those rooms and areas approved by the Bureau for the
children’s use. Please talk to us if you have any questions about the center space.
Our center must offer parents of enrolled children ample opportunity to participate in and observe the
activities of the center. Parents wishing to participate in the activities or operations of the center should
discuss their interest with the center director or their designee who can advise you of what opportunities
are available.
Parents of enrolled children may visit our center at any time without having to secure prior approval from
the director or any staff member. Please feel free to do so when you can. We welcome visits from our
parents.
Our center must inform parents in advance of every field trip, outing or special event away from the
center and must obtain prior written consent from parents before taking a child on each such trip.
Our center is required to comply with the New Jersey Against Discrimination (LAD), P.L. 1945, c. 169
(N.J.S.A. 10:5-1 et seq.), and the Americans with Disabilities Act (ADA), P.L. 101-336 (42 U.S.C.
12101 et. Seq.). Anyone who believes the center is not in compliance with these laws may contact the
Division on Civil Rights in the New Jersey Department of Law and Public Safety for information about
filing an LAD claim at (609) 292-4605 (TTY users may dial 711 to reach the New Jersey Relay Operator
and ask for (609) 292-7701), or may contact the United States Department of Justice for information
about filing an ADA claim at 1-(800)514-0301 (voice) or (800)514-0383 (TTY).
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After School Application 2015-2016 Teaneck Recreation Department
Information to Parents (page 3)
Anyone who has reasonable cause to believe that an enrolled child has been or is being subjected to any
form of hitting, corporal punishment, abusive language, ridicule, harsh, humiliating or frightening
treatment or any other kind of child abuse, neglect, or exploitation by any adult, whether working at the
center or not, is required by State law to report the concern immediately to the Division of Youth and
Family Services Office of Child Abuse Control. Toll Free at (800) 792-8610 or to any DYFS District
Office. Such reports may be made anonymously.
Parents may secure information about child abuse and neglect by contacting, Community Education
Office, Division of Youth and Family Services, P.O. Box 717, Trenton, New Jersey 08625-0717.
9/10
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After School Application 2015-2016 Teaneck Recreation Department
POLICY ON THE RELEASE OF CHILDREN
A. Each child may be released only to the child’s custodial parent(s) or person(s) authorized by the
custodial parent(s), to take the child from the center and to assume responsibility for the child in an
emergency if the custodial parents cannot be reached.
1. The provision that a child shall not be visited by or released to a non-custodial parent
the custodial parent specifically authorizes the center to allow such visits or
release in writing. This written authorization, including name, address and phone
number shall be maintained in the file.
2. Circumstances may require staff members to seek additional confirmation and/or
verification of consent before releasing a child from the center.
3. Authorized persons must be able to present valid identification prior to release of the
child. Authorized persons must be 16 years or older to assume custody of the child from
the center.
B. Written procedures required to be followed by staff member(s) if the parent(s) or person(s)
authorized by the parent(s), as specified in (A) above, fails to pick-up a child at the
time of the center’s daily closing:
1. The child is supervised at all times;
2. Staff members attempt to contact the parent(s) or person(s) authorized by the parents;
3. An hour or more after closing time, and provided that other arrangements for releasing
the child to his/her parent(s) or authorized person(s) have failed and the staff member(s)
cannot continue to supervise the child at the center, the staff member shall call the Division’s
24 hour Child Abuse Hotline (1-800-792-8610) to seek assistance in caring for the child until
the parent(s) or person(s) authorized by the child’s parent(s) is able to pick-up the child.
C. Written procedures required to be followed by a staff member(s) if the parent(s) or person(s)
authorized by the parent(s), appear to be physically and/or emotionally impaired to the
extent that, in the judgment of the director and/or staff member, the child would be
placed at risk of harm if released to such an individual:
1. The child may not be released to such an impaired individual;
2. Staff members attempt to contact the child’s other parent or an alternate
person(s) authorized by the parent(s); and
3. If the center is unable to make alternative arrangements, as noted
above, a staff member shall call the Division’s 24-hour Child Abuse Hotline
(1-800-792-8610) to seek assistance in caring for the child.
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After School Application 2015-2016 Teaneck Recreation Department
POLICY ON THE MANAGEMENT OF COMMUNICABLE DISEASES
If a child exhibits any of the following symptoms, he or she should not attend school. If such symptoms
occur at school, the child will be removed from the classroom, and the parent(s) will be called to take
them home.
Severe pain or discomfort
Acute diarrhea
Episodes of acute vomiting
Elevated oral temperature of 100 degrees Fahrenheit
Sore throat or severe coughing
Yellow eyes or jaundice skin
Red eyes with discharge
Infected untreated skin patches
Difficult or rapid breathing
Skin rashes lasting longer than 24 hours
Swollen joints
Visibly enlarged lymph nodes
Stiff neck
Blood in urine
Once the child is symptom free and or fever free for 24 hours, or has a physician’s note stating that he or
she no longer poses a serious health risk to themselves or others, he or she may return to school.
If a child contracts any of the following diseases, please report it to us immediately. The child may not
return to school without a doctor’s note stating that the child presents no risk to themselves or others.
TABLE OF EXCLUDABLE COMMUNICABLE DISEASES
Respiratory Illnesses Gastro-intestinal Illnesses Contact Illness
Chicken Pox Giardia Lamblia* Impetigo
German Measles* Hepatitis A* Lice
Homophiles Influenza* Salmonella* Scabies
Measles* Shigella*
Strep Throat Escherichia coli*
Meningococcus*
Tuberculosis
Mumps*
Whooping Cough
*Reportable diseases, as specified in N.J.A.C. 10:122-7, 10 (a).
If your child is exposed to any excludable diseases at school you will be notified in writing.
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Application Form Page 2 Teaneck Recreation Department
Please supply required information
CHILD’S NAME _______________________Age _______ Date of Birth ____________________
ADDRESS_______________________________________________________________________
EMERGENCY CONTACT __________________ Phone # ______________ Cell#_____________
CHILD’S MEDICAL INFORMATION
Is your child under any medical/physical/dietary restrictions? __________Yes ________No
If yes, _____________________________________________________________________________
Is your child taking any medication? ____________Yes ________No
Please name________________________________________________________________________
Has your child been under a doctor’s care or hospitalized within the past three years ?______Yes ______No
If yes ____________________________________________________________________________
Is your child allergic to any medication/food/insect stings? ___________Yes _________No
If yes_______________________________________________________________________________
Any special needs that we should be aware of ? _____________Yes ________No
Please explain ______________________________________________________________________
.
Parent Signature ___________________________________Date :____________________________
Director’s Signature ________________________________Date:_____________________________
I HEREBY GIVE PERMISSION TO HAVE MY CHILD PICKED UP AT THE RECREATION CENTER
BY THE FOLLOWING: (ALL AUTHORIZED PERSONS ARE 16 YEARS OR OLDER)
1. Name ____________________________ Phone __________________ Relationship_______________
2. Name ____________________________ Phone __________________ Relationship_______________
3. Name ____________________________ Phone __________________ Relationship_______________
PARENT’S SIGNATURE _______________________________DATE ______________________________
MOTHER’S NAME _______________________ FATHER’S NAME _____________________
Home Phone # ____________________________ Home Phone # _________________________
Bus. #___________________________________ Bus. # ________________________________
Cell #___________________________________ Cell # ________________________________
As parent/guardian of the above participating child, I certify that he/she is in good physical health and
has no disability or ailment that would prevent he/she from participating in all of the activities of the
program, except as noted on application.
Parent/Guardian signature ___________________________ Date _____________
After School Application 2015-2016 Teaneck Recreation Department
Child’s Name______________________________
CHILD’S HEALTH RECORD - School Year 2015-2016
IMMUNIZATIONS AND TESTS
(Exact dates from certificates signed by physician or official agency)
EMERGENCY MEDICAL INFORMATION
Has or is subject to: (check and give details)
_______*Asthma _______ Convulsions ______ Heart Trouble ______ Diabetes _____Fainting Spells
_______ High Blood Pressure _______ Allergy or reaction to medicine, food plant, animals or insect
_______ Any other condition that may require emergency/special care or knowledge
Explain restrictions or limitations:
*If your child has asthma they must have their inhaler with them and know how to use it.
MEDICAL HISTORY
Date of most recent physical exam (Month & Year) _________________________________________________
Any current health problems ___________________________________________________________________
Remarks ___________________________________________________________________________________
Date ______________________ Physician’s Signature ________________________Telephone # ___________
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Diphteria
Pertussis
Tetanus
Polio Vaccine Measles Rubella Varicella HIB Hepatitis
“B”
Mantoux
TB
Date Date Specify
type
Date Date Date Date Date Date
1st
2nd
3rd Flu Vaccine
1st Booster Date
2nd Booster
3rd Booster
TEANECK BOARD OF EDUCATION
DAYCARE DROP OFF/PICK UP REQUEST FORM (Your child must be eligible for busing to request a daycare stop)
REVISED 1/20/05
Please complete this form if your child will need to be dropped or picked up at a licensed daycare in Teaneck.
The Teaneck Board of Education is responsible for the safe transport of students to and from their home. The district is not
obligated to transport a student to any other location by law. However, as a courtesy, the Teaneck school district will review
and possibly approve a pick-up or drop off request for a licensed daycare center as long as it is located in Teaneck and the bus
route can efficiently and safely accommodate a stop at the licensed facility.
Note: All request for daycare stops for classified students who are picked up and dropped off at home by vans must be
submitted to the special services department in writing (verbal requests are not acceptable per the instructions on the form
below). No one in the school district (to include bus companies) may change a classified student’s drop off or pick up location
except the special services department. All requests will be reviewed by Mr. Anthony Calandrillo, Coordinator of Child Study
Teams, or his designee. If approved, you will be contacted by phone or mail by the special services department. Requests
received after August 1st will be implemented the second week of school if approved.
All requests for children who ride big buses (they walk to corner bus stops) see below.
______________________________________________Cut Here_______________________________________________
REVISED 1/20/05
DAYCARE REQUEST FORM
Please note, all request must be in writing and forwarded to the proper persons as noted below.
_____ My child is classified or is in the process of being classified by the special services department IF THIS
IS CHECKED INDICATING THAT THE CHILD IS CLASSIFIED, THIS FORM MUST BE FORWARDED
TO THE SPECIAL SERVICES DEPARTMENT FOR REVIEW AND POSSIBLE APPROVAL (Fax: (201)833-
5532 or Address: One Merrison Street, Teaneck). If approved, you will be contacted by phone or mail by the special
services department as to the start date.
______ My child rides a big bus (he/she walks to a corner pick up/drop off location) and will attend the Rodda Center
Recreation Program. YOU MUST RETURN THIS FORM TO THE RECREATION DEPARTMENT, 250
COLONIAL COURT, TEANECK (ATTN:LISA SKULNIK) WHEN YOU RE-REGISTER OR REGISTER YOUR
CHILD. The Recreation Center will provide the school district with a list of students who have paid and are
accepted to their program.
______ My child rides a big bus (he/she walks to a corner pick up/drop off location) and will attend another daycare location:
You must return this form to the school secretary for review and approval.
Requests may be submitted for next year as early as June. However, they must be submitted no later than July 30th for review
and possible approval order to be implemented within the first two weeks of school.
School of attendance: ___________________________________________________________________________________
Child Name _______________________________________Grade _________ D.O.B. ______________________________
Parent Name________________________________ Home Address ___________________ Day Phone_________________
Other Location Request AM ______________________________________________(Or NONE)
Name, address, phone number
I have read the transportation procedures to change my child’s pick-up and/or drop off location and understand that in order for
my child to be considered for a daycare stop, she or he must be eligible for busing from our home to the school and I must
complete the name, address, phone number of the daycare (or babysitter), sign and return this form to the proper person for
approval.
Date __________________________________________ Parent Signature ___________________________________
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After School Application 2015-2016 Teaneck Recreation Department
POLICY ON AGGRESIVE BEHAVIOR
Dear Parents:
Our mandate is to provide a safe environment in all Recreation Department Youth Division
programs. Therefore, we have set forth the following policy on aggressive behavior. This policy
addresses physical contact between children and/or verbal/physical confrontational behavior of
parents.
Any aggressive behavior such as hitting, kicking, punching, play fighting and/or fighting during the
program that results in physical altercations will not be tolerated. In addition, any physical/verbal
threats of any kind by children or parents will not be tolerated. Any such behavior will be addressed
as follows:
First offense 3 day suspension
Second offense 5 day suspension
Third offense Dismissal from the program
An Aggressive Incident Report Form describing aggressive behavior will be presented to keep you
informed of any incidents of disciplinary action.
If your child is dismissed from the program, no refunds will be permitted.
We would like you to address this with your child/children to make them understand that physical/
verbal aggression is not the solution to any problem and will not be tolerated.
We thank you in advance for your cooperation. If you have any questions you may call me at
201-837-7130 ext. 7010. Please sign below and return this letter to us.
Sincerely,
Lisa Skulnik Assistant Superintendent of Recreation
_____________________________ __________________________
Parent Signature Date
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After School Application 2015-2016 Teaneck Recreation Department
PAYMENT SCHEDULE 2015-2016 Date Due Application Fee Amount Period Covered
per Child Sibling
At Registration $15.00 (per child)
At Registration $150.00 $125.00 September 2015
August 1 $150.00 $125.00 June 2016
September 1 $150.00 $125.00 October 2015
October 1 $150.00 $125.00 November 2015
November 1 $150.00 $125.00 December 2015
December 1 $150.00 $125.00 January 2016
January 1 $150.00 $125.00 February 2016
February 1 $150.00 $125.00 March 2016
March 1 $150.00 $125.00 April 2016
April 1 $150.00 $125.00 May 2016
There is a $15.00 non-refundable application fee for all participants for the After School Program.
LATE PICK UP FEE:
There will be a late pickup fee of $30.00 per family after 6:15 p.m. Your child will not be permitted to return to the
program unless this fee is paid.
PLEASE NOTE: Payment is due on the first of the month in the Administrative Office. If payment is not received
by the close of business, 5:00 p.m. on the 5th of the month there will be a $50.00 non-negotiable late charged assessed
per family. Failure to pay by the 12th of the month will result in your child being automatically suspended from the
program until payment is made.
Monthly payments should be made at the Recreation Department’s Administrative Office between the hours of 8:15
a.m. to 5:00 p.m.(Tuesday until 6:30 p.m.), Payments can also be mailed or put in drop box located on the first floor of
the Richard Rodda Community Center.
ALL Checks should be made payable to the “TOWNSHIP OF TEANECK”.
Page 2
TOWNSHIP OF TEANECK RECREATION DEPARTMENT - YOUTH DIVISION
Richard Rodda Community Center
250 Colonial Court
Teaneck, New Jersey 07666
(201) 837-7130 ext. 7010
We welcome you to the After School Child Care Program, held at the Richard Rodda Community Center.
The program operates from school dismissal to 6:00 p.m. Monday thru Friday starting Thursday, September 4, 2015 and
ending Tuesday, June 23, 2016. The program follows the Teaneck Public School Calendar including snow days,
holidays, vacations, as well as all Municipal holidays. Children may participate all five days or any combination of days
during the week; however, no reduction of fee will apply for partial attendance.
The philosophy of the program is to enable the child to foster their self-esteem socially, physically and emotionally
through age appropriate activities. Daily activities include time for homework (with staff assistance), cooking, “Get Fit,
Get Healthy” activities, Drop Everything and Read Fridays, spelling bees, sports, free play, arts and crafts, and special
events (science fair, talent show, mini Olympics). The program offers children a game room featuring ping pong,
foosball, pool, and an assortment of board games. We believe that by incorporating all of the mentioned, we encourage
independent thinking, and cultivate individual talents. Daily snacks are provided, as well as weekly Thursday Pizza, and
end of the month Pasta and Salad Thursday.
No child will be permitted to enroll in the program if over age thirteen after the date of September 30, 2015.
There is an initial application fee for each child of $15.00. These application fees are due at the time of registration and
are non-refundable.
Registration will begin Wednesday, May 28 by either Mail In or Drop Box located on the first floor of the Richard
Rodda Community Center. Registration for our program is open to residents of Teaneck only.
For your convenience, a check list with all necessary documents to be completed and returned is provided:
______ Completed Application
______ Day Care Drop Off/Pick Up Request Form
______ Proof of Residency
______ $15.00 application fee payable to “Township of Teaneck”
______ Signed “Aggressive Behavior Policy” Form
______ Signed “Expulsion Policy” Form
______ Completed Child Health Record (Immunization History from Doctor)
If you have any questions or need further information please call 201-837-7130, ext 7010.