• NDIIS PERMISSION FORM

    NDIIS PERMISSION FORM

  • Through the North Dakota Immunization Information System (NDIIS), with written parental permission, Active Minds Academy may access you child’s immunization records. All records are kept confidential and the only AMA Employees with access to the system is the owner or director. Pease see the paragraph below for information on Active Minds Academy’s Immunization Policy.

     

    Active Minds Immunization Policy

    All enrolled children are required to be fully up-to-date with their immunizations with the exception of those with a signed medical exception from a physician. A copy of your child’s immunizations is required to be turned in and kept on file throughout your child’s enrollment at Active Minds Academy. Out of date immunizations will cause a suspension in care.

     

    *Immunization information is only available if immunizations are received within the state of North Dakota, any immunizations received out of state must be turned in by the child’s parents or guardians.

  • Child's DOB:*
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  • Parent/Guardian Authorization:*
  • Date:*
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  • CHILD INFORMATION

  • Gender:*
  • Child's DOB:*
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  • Typical Weekly Schedule:

    The schedule you provide will be used weekly unless given other notification. Reminder: Per Active Minds Academy policy, children may only be at the center a maximum of 10 hours per day.

  • Medical Information:

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  • Does your child have any special requirements for their diet?*
  • Does your child have any special requirements for allergies? If yes, please complete a Specialize Care Plan. This form can be found on the enrollment tab of the center's website.*
  • Does your child have any special requirements for behavior? If yes, please complete a Specialize Care Plan. This form can be found on the enrollment tab of the center's website.*
  • Does your child have any special medical requirements? If yes, please complete a Specialize Care Plan. This form can be found on the enrollment tab of the center's website.*
  • Is your child involved in any specialize care, such as:

  • Please list any professionals involved with your child:
  • Do you have any worries or concerns about your child?*
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  • AUTHORIZATION FOR NON-PRESCRIPTION PRODUCTS

  • All over the counter products require written parental permission on a yearly basis. The following products may be applied to my child in accordance with the manufacturer’s instructions on the original container. 

    This form will be completed on a yearly basis.

     

  • Child's DOB:*
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  • The following products may be used for my child:

  • Date*
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  • Date
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  • AQUATIC ACTIVITY PERMISSION FORM

  • Child's DOB:*
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  • I understand that Active Minds Academy will maintain a safe staff to child ratio while participating in aquatic activities and closely monitor my child. Children will never be left unattended.

  • My child may participate in:
  • Please best describe your child's swimming abilities. My child is:

  • I hearby give consent for my child to participate in water activities while enrolled at Active Minds Academy. 

    This form will be completed on a yearly basis.

  • Date:*
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  • Date:
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  • INFANT SLEEP PERMISSION FORM

  • With written parental permission, the provider may place one individual blanket or sleep sack, a pacifier, and one security item that does not pose a risk of suffocation to the infant in the crib or pack and play while the infant is sleeping or preparing to sleep. 

    The American Academy of Pediatrics recommends keeping soft objects and loose bedding (including blankets) out of the crib or pack and play to reduce the risk of SIDS, suffocuation, entrapment, and stragulation for infants under the age of 12 months. The AAP recommends the use of pacifiers for sleep. Studies have reported a protective effect of pacifiers on the incidents of SIDS. Pacifiers are checked for tears before each use.

  • Blankets:

    • A written order from a health care provider is required to use more than one blanket.
    • If an infant is being swaddled, the blanket should no come any higher than to the shoulders of the infant. In addition, the blanket needs to be loose enough for a hand to fit between the blanket and the infant's chest. The blanket should be keep loose around the infant's hips.
    • Swaddling is recommended, by the AAP, to be discountinued once the infant reaches two months of age, or sooner if the infant is showing signs of rolling.
    • North Dakota State Licensing Regulations requires swaddling to be discountinued one an infant becomes mobile.
    • A written order from a health care provider is required to continue swaddling after an infant becomes mobile. 

    Sleep Sacks:

    • Swaddle sleep sacks (with arm panels) are reecommended to be discontinued once an infant reaches two months of age, or sooner if the infant is showing signs of rolling. Once the infant is showing signs of rolling or reaches two months of age, sleeveless sleep sacks should be used.

    Pacifiers:

    • Pacifiers are not allowed to be attached to a clip or strap. 
    • Pacifiers attached to a stuffed animal or toy are not to be used within the center.

    Security Items:

    • Necklaces, including teething necklaces, are not allowed.
    • Bibs are not to be worn while sleeping.
    • Headbands are to be removed while sleeping.
  • I have read the above stated information and give Active Minds Academy permission to use the following checked items when my infant is sleeping or preparing to sleep:
  • Date:*
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  • Date:
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  • INFANT SOCIAL RESUME

  • Child Information:

  • Child's DOB:*
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  • Family Information:

    Please list any family members living in your home:

  • Feeding Information:

  • Please check what your child's daily nutritional intake is:*
  • If your child is breast fed, do you plan to:
  • If your child is formula fed, do you plan to:

  • My child typically drinks ounces every hours.

  • Sleep Information:

  • My child typically sleeps from * PM to * AM.

  • Does your child have trouble falling asleep or staying asleep?*

  • Understanding Your Child:

  • Does your child have a comfort toy, blanket or soother?*
  • Does your child separate from you easily?*
  • Does your child use a pacifier?*

  • What cues does your child show when they need something?

    For example: Rubbing their eyes when tired.

  • Does your child have any individualize needs? If yes, please complete a Specialize Care Plan. This form can be found on the enrollment tab of the center's website.*

  • SFN 845: CHILD INFORMATION SHEET

    This form is required by the State of North Dakota and is required to be completed on a yearly basis.

  • Child Information:

  • Child's DOB:*
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  • Date of Enrollment:*
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  • Parent/Guardian #1 Information:

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  • Parent/Guardian #2 Information:

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  • Emergency Authorization:

    In case of an emergency and parents cannot be reached, who should be contacted?
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  • I hearby authorize the Early Childhood Program to secure emergency medical treatment for my child under the follwoing conditions:

    1. An emergency or unanticipated condition necessitates immediate action for the presservation of the life or health of the child, and
    2. Reasonable attempts to contact me have failed.
  • Date*
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  • Date
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  • Authorization to Release Child:

    Unless otherwise authorized by you in writing, only the parent or legal guardian may pick up your child(ren) from the Early Childhood Program. List below any others you wish to authorize for this purpose.
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  • The people listed below are NOT allowed to pick up my child:

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  • SFN 847: PARENT'S STATEMENT ON HEALTH OF CHILD

    This form is required by the State of North Dakota and is required to be completed on a yearly basis.

  • Child Information:

  • Child's DOB:*
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  • Date of Enrollment:*
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  • Enrollment Status:

  • Parent/Guardian Information:

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  • Medical Information:

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  • Last Visit to Doctor:*
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  • Does your child have any food, medication or environmental allergies?*
  • Please check if you child has any of the following conditions. If any of the conditions apply, please complete a Specialize Care Plan. This form can be found on the enrollment tab of the center's website.

  • Is your child under current medical treatment?*
  • Does your child take any medication on a daily basis?*
  • Is there a health care plan for your child? This may include but is not limited to Allergy Action Plans, Asthma Action Plans, etc.
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  • I certify that the above information is true to the best of my knowledge.

  • Date*
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  • Date
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  • Should be Empty: