Encouraging Kids Online Enrollment

Encouraging Kids Family Resource Center
Child's Full Name
281 Lawrenceville-Pennington Road, Pennington, NJ 08534 Phone: 609-848-1400 Fax: 609-848-1401 www.encouragingkids.org

Navigating the sometimes difficult, complicated, confusing application and registration paperwork for services alone can be overwhelming at times for special needs families. Our staff will help you with the application and registration process along with any "red tape" you encounter along the way.
- E ligibility for "Summer Camp" funding with PerformCare DOES NOT impact your child's eligibility for respite afterschool / extended school year services; your child may be eligible for both.
- Eligibility for respite services are NOT income - based.
Call or email us today to schedule an appointment with one of our staff members.

We look forward to serving your family soon.

Liz Porcelli, M.Ed., Executive Director

Encouraging Kids Family Resource Center
Parent Full Name
Parent / Guardian Email
example@example.com
Parent / Guardian Phone Number

Area Code Phone Number
Federal Law protects the confidentiality of the information disclosed. Federal regulations (42CFR Part 2) prohibit making further disclosure of thisinformation without specific written consent of the person or who pertains, or as otherwise permitted by such regulations. General authorization for the release of medical information IS NOT sufficient for this purpose.
Child Date Of Birth

Month Day Year
Date
My child is currently determined eligible for Respite Services with DDD / PerformCare / and his/her CYBER ID number is
I have applied for respite services through PerformCare for my child and am awaiting
I plan to apply for respite services through PerformCare for my child.
I would like my child placed on the Encouraging Kids Family Resource Center Provider Queue in order to be admitted to their program if eligible.
Parent / Guardian Signature

Clear
Date

Month Day Year
Date
Parent / Guardian Signature Date
My child is not eligible for respite services through PerformCare/DDD. / am interested and recreation services. I am interested in private pay options.
Child Enrollment Form
Child Address
Parent / Guardian Address (if different)
Parent / Guardian Email
example@example.com
Parent / Guardian Phone Number

Area Code Phone Number
Emergency Contacts:

Available to pick up your child in an emergency if you cannot be reached
Emergency Contact 1

First Name Last Name
Emergency Contact 1 Phone Number

Area Code Phone Number
Emergency Contact 2

First Name Last Name
Emergency Contact 2 Phone Number

Area Code Phone Number
Emergency Contact 3

First Name Last Name
Emergency Contact 3 Phone Number

Area Code Phone Number
Encouraging Kids Family Resource Center
Doctor / Clinic Information (Name, phone, address)
Family Information
Person(s) allowed to pick up child other than parent
Names, phone numbers
Persons NOT ALLOWED to pick up child
Names
Primary Language spoken at home:
Medical Declaration Statement for School-Aged Care
Child's Full Name:
Date of Birth:

Month Day Year
Date
Current School Child Attends (Name & Town/City)
Child's Primary Diagnosis:
Age when diagnosed:
Asthma

Diabetes Convulsions/Seizures Hearing Impaired Visually Impaired Asthma Heart Condition Liver Disease High Blood Pressure
Other Health Issues
List any allergies (food or medicine) for your child
Is your child under any medical or physical restrictions?

Yes No
If yes, please explain:
Child's Immunization Record

Browse Files

Cancel of
**IMMUNIZATION RECORD MUST BE SUBMITTED WITH APPLICATION – NO EXCEPTIONS
Physician's Name:
Phone:
Address:
As the parent/guardian of the above mentioned child who will be attending this program, I certify that he/she is in good physical health and may participate in all of the activities of the Respite Care Program as designated by Encouraging Kids Family Resource Center, except as noted above.
Sign

Clear
Date

Month Day Year
Date
Parent’s insurance or medical assistance plan: Name of Insurance/Company:
Name of Insurance/Company:
ID Number:
Policy is in name of:
Customer Service Phone Number:
Personal Information Record for School-Aged Children
Child's Name:
Age:
Does your child exhibit aggressive behavior? Please describe:
Has your child ever injured another child or adult? Please describe:
Please describe any triggers (sounds, smells, actions) if known:
What does your child usually prefer to do after arriving home from school or on weekends?
What is your child's favorite snacks?
Does your child have a strong dislike for certain foods?
If so, what?
Are there any foods your child is not permitted to eat?
Are there any activities that you DO NOT want your child to participate in?
If so, please explain:
Authorization to Leave the Premises
I, (name of parent/guardian) permit my child Encouraging Kids Family Resource Center Respite Programs on predesignated dates as indicated on Respite Calendar(s) for the following purposes:

Field Trips/Outings Walks Other outdoor activities In case of an emergency
Parent / Guardian Signature

Clear
Permission to Use Sunscreen
My child, before going outside on warm, sunny days. I, (name of parent/guardian) will provide sunscreen with a sun protection factor (SPF) of 15 or more; without Paba as per EKFRC’s recommendation. Paba gives some children blotchy rashes. I will also make my child’s name of his/her sunscreen PLASTIC container with a permanent marker and keep it in my child’s bag at the facility.
Parent / Guardian Signature

Clear
Date

Month Day Year
Date

Sick Child Policy
We understand the need for parents to have safe, regular, reliable care for their children. We also know how difficult it may be to stay home with a sick child. Our priority here at Encouraging Kids is to maintain a safe, healthy, nurturing environment for everyone. To do this we must insist that you keep your child home if he/she has any of the following:

Fever, irritability, lethargy, persistent crying, or difficulty breathing - can be signs of

An upper respiratory illness , such as bronchiolitis or influenza.

The common cold with coughing, sneezing, runny nose.

Diarrhea, Vomiting, Bloody stools

or stools containing mucus. These could be the sign of a

viral or bacterial infection. (Give your doctor a call!)

Rash. This is reason to keep your child home unless you know for sure that it's not linked to

an infection (for example, if you know it's a reaction to eating strawberries

Chicken pox. Child is no longer contagious once all the sores have dried and crusted over.

Impetigo. Kids with this skin disease are no longer contagious after 24 hours of antibiotics.

Scabies. Once treated with a topical insecticide, it's no longer contagious.

Bacterial conjunctivitis (pinkeye) and yellow discharge from the eye.

Strep throat. It's usually not contagious after 24 hours of antibiotics.

Mouth sores that cause excessive drooling. Wait until your doctor says they're not

Head lice. Your child can return after he or she has been thoroughly treated.
Any other contagious diseases or illnesses not listed above.

If you are contacted to pick up your child by our staff we expect you to be there as soon as possible. If we cannot reach you directly we expect someone else on your child’s emergency contact list will pick your child up. If your child is not picked up within 60 minutes of our call we must, as mandatory reporters, contact DCP&P (formerly DYFS) to have them pick up your child until you can be reached. We can all work together to keep our children as healthy as possible.

I (print name) above sick child policy. I understand continually violating this policy will result in my child being discharged from Encouraging Kids programs.

understand and agree to abide by the
Parent / Guardian Signature

Clear

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Encouraging Kids Family Resource Center

Child Enrollment Form

Emergency Contacts:

Encouraging Kids Family Resource Center

Family Information

Medical Declaration Statement for School-Aged Care

**IMMUNIZATION RECORD MUST BE SUBMITTED WITH APPLICATION – NO EXCEPTIONS

Personal Information Record for School-Aged Children

Authorization to Leave the Premises

Permission to Use Sunscreen

Sick Child Policy