Giving Tree School Admission Form Email * Child's Name * First Name Last Name Nickname Child's Preferred Pronouns * Age at admission * Date of Birth * MM DD YYYY Place of Birth * Child's Primary Language * Languages spoken at home? * Identification Sheet The following information about physical characteristics is requested for purposes of child identification in a pre-verbal child or in an emergency situation (does not impact enrollment). Race/ethnicity demographic information may also be used for grant-writing purposes. Eye Color * Hair color * Race/ethnicity * Sex * Height * Weight * Please describe any identifying marks * Parent / Guardian 1 Information Parent/Guardian 1 Name * First Name Last Name Parent/Guardian 1 Relationship to Child * Parent/Guardian 1 Preferred Pronouns * Parent/Guardian 1 Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Does the child live full-time at address 1? * Yes No Parent/Guardian 1 Cell Phone Number * (###) ### #### Parent/Guardian 1 Home Phone Number (###) ### #### Parent/Guardian 1 Occupation * Parent/Guardian 1 Place of Work * Parent/Guardian 1 Typical Work Schedule Is there another parent/guardian? Yes No Household Members Please list any other individuals residing in the household, their ages, and their relationship to the child. * Custody Are there any court orders, custody agreements, or restraining orders pertaining to the child? Please describe. * Medical Information Does the child have any known allergies? If yes, please explain. * Does the child have any chronic health conditions? Please explain. * Does the child have an Individual Health Care Plan (IHCP)? Please explain. * Does the child have any special limitations or concerns? * Please list any medications or supplements given regularly, and what they are for. Please list any medications that need to be administered at school, and what they are for. Were there any complications at birth? Please explain. Please describe any serious illnesses or hospitalizations. Please describe any special physical conditions or disabilities. Developmental History Please share the approximate age at which your child reached the following milestones: Sitting * Crawling * Walking * Talking * Does your child have any speech difficulties? Please explain. * Special words to communicate needs? Developmental challenges or delays? Eating Habits Is your child on any special diet (vegetarian, vegan, gluten-free, etc.)? Please describe. * Favorite foods * Foods refused * Special characteristics or difficulties eating Toilet Habits Your answers to these questions will not impact enrollment, but will give us a general understanding of your child's progress with toileting skills. Does your child wear diapers? * Yes No Sometimes Only for sleeping How does your child indicate bathroom needs (including any special words)? Is your child ever reluctant to use the bathroom? * Does your child have accidents? * Please describe your child's current stage of toilet training, and (if applicable) how you would like us to approach toileting while your child is in our care. * Sleep Habits Please share the approximate times your child typically wakes and sleeps over a 24-hour period. * Does your child become tired and nap during the day? * Yes No Sometimes Describe any special characteristics or needs for napping. Social Relationships Are there individuals who play a major role in caregiving, besides the parents / guardians already listed? Please describe. * Is your child adopted? * Yes No Fostering Fostering with intent to adopt Is there anything you would like to share about your child's experience of gender identity (their own or others')? How would you describe your child? * Please describe your child's previous experience with groups (schools, daycare, playgroups, etc.). * Does your child have friendships with other children? * What is your child's reaction to strangers? * What are your child's favorite toys and activities? * Does your child have any particular fears? Please describe. * Had your child experienced any traumatic events? * How do you comfort your child? * What methods of behavioral management are used in your home(s)? * How would you describe your home life? * What does your child's typical day look like? * What are your goals for your child's preschool experience? * If your child has been at Giving Tree before, please share any highlights about what you valued, as well as any difficulties or challenges experienced. Is there anything else you would like us to know about your child? Transportation Plan Please provide us with information on your child's transportation to and from school on a typical week. * Include name of adults responsible for dropping off and picking up, approximate times of drop-off and pick-up, and mode of transportation (personal vehicle, carpool, etc.). If the plan will differ depending on the day of the week, please include the plan for each day. Pick-Up Consent * Please list the individuals (besides parent/guardians) you would like to be authorized to pick your child up from school. Transportation: Signature * Permissions Please indicate your consent for the following items: Herbal-based insect repellent (no DEET) * Yes No Mineral-based sunscreen * (no nano, no parabens) Yes No Off-site walking field trips under supervision of GT staff * Yes No Media Permissions * Occasionally we use images or videos of students for school marketing purposes or teacher education. Please indicate your permission preference for your child below. Full permission: All uses Partial Permission: Print media and print advertising only In-house only: Only for use inside Giving Tree. Permissions: Signature * Class Contact List The class list is distributed to current families each year to facilitate connection for social get-togethers. This information is not published online or shared outside of currently enrolled families. Do you give permission to include your child's name and family contact information on the class list? * Yes No COR Advantage Online Assessment Tool Over the course of the coming school year, Giving Tree teachers will be observing your child and collecting anecdotes and evidence about your child's progress. This information will be compiled using an online tool called COR Advantage, which is a branch of the HighScope Educational Foundation. The COR Advantage application is hosted on the servers of the Red-e Set Grow. COR Advantage is aligned with the assessment standards of the MA Dept. of Early Education and Care (EEC), the state licensing agency for Giving Tree School. The information that we gather about your child will be compiled into a report that parents will receive in printed form and review twice each year, for the January and May parent-teacher conferences. The printed report will then be placed in your child's physical school file. Among the identifying information that will be entered into the COR Advantage online database is the following: Child's first and last names; Parent first and last names; Teacher first and last names; Child's birthdate; Child's quotes and actions. The COR online assessment is a valuable tool that enables Giving Tree teachers and families to pinpoint areas of growth over time and developmental opportunities for our students. More information about the COR Advantage tool can be found at: http://coradvantage.org More information about Red-e Set Grow and their privacy protection policy can be found at: http://www.redesetgrow.com Giving Tree School and the staff of Giving Tree School will never enter any other identifying information into the COR records, including home addresses, or children's schedules. Additionally, the COR assessment reports will never be shared with any other agency or educational facility without written parental consent. Please indicate your consent to enter your child's information into the COR Advantage online software. * If you choose "no", your child will not receive an assessment report at parent-teacher conferences. Yes, I consent No, I choose to opt out COR: Signature * First Aid and Emergency Medical Care Consent Form I authorize staff at Giving Tree School who are trained in the basics of first aid / CPR to give my child first aid / CPR when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to Baystate Franklin Medical Center and to secure the necessary medical treatment for my child. First Aid/Emergency Care: Signature * Child's Physician Name * Child's Physician Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Child's Physician Phone Number * (###) ### #### Child's Health Insurance Plan Provider * Health Insurance Policy# * Primary Policy Holder's Name * Primary Policy Holder's Birthdate * MM DD YYYY Emergency Contacts Every effort will be made to reach primary caregivers first in case of any emergency. In the event of an emergency, children will be released ONLY to persons listed below. Proof of identification will be required if the listed individuals are unknown to Giving Tree staff members. Please list the order in which to contract primary caregivers and other emergency contacts while your child is at school. Primary Emergency Contact Name * Please list someone other than parent/guardian. Emergency Contact 1: Relationship to Child * Emergency Contact 1 Phone Number * (###) ### #### Emergency Contact #2 Name * Please list someone other than parent/guardian. Emergency Contact 2: Relationship to Child * Emergency Contact 2 Phone Number * (###) ### #### Permission to Release Child to Emergency Contacts I give permission for Giving Tree School to release my child into the care of the emergency contacts listed above. Permission to Release to Emergency Contacts: Parent/guardian signature * Thank you for submitting your child’s admission form!