LADC Student Packet: Family Information and Permissions
Discovery Center Location Attending:
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Please Select
Community of Grace/White Bear Lake
Faith Lutheran/Forest Lake
Grace Lutheran/Apple Valley
Hosanna Lutheran/Forest Lake
Our Savior's/Stillwater
Redeemer Lutheran/White Bear Lake
St. Paul Lutheran/Wyoming
Trinity Lutheran/Stillwater
Valley of Peace/Golden Valley
Trinity of Minnehaha Falls/Minneapolis
Student's Full Name
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Student's Birthdate
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Month
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Day
Year
Date
Child's Nickname / Preferred Name
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Parent(s) Occupation(s)
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Parent(s) Employer(s)
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Language Spoken at Home besides English
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Child's favorite activity/toy/snack, etc.
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Regarding toileting, your child is currently...
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Please Select
In regular underwear and toilet independent
In regular underwear but needs some help toileting
Wearing pull-ups, beginning to toilet-train
Wearing diapers, not toilet-trained
Describe any group settings your child has been involved in, if any
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Type of correction or redirection that is most successful your child
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Best way to comfort your child,
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Does your child have any strong likes or dislikes?
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Does your child have any behaviors that you find challenging?
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Choose the words that best describe your child:
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Confident
Curious
Verbal
Responsible
Challenging
Cooperative
Cautious
Helpful
Leader
Follower
Exuberant
Reserved
Observer
Playful
Moody
Independent
Happy
Good Listener
Quiet
Creative
Friendly
Describe any recent family events or changes in the last six months (ie: divorce, death, moving, illness, new sibling, etc.)
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Please share any information about your family's culture, religion, home language and/or family structure
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What holidays and family traditions does your family participate in?
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NON-DISCRIMINATION POLICY: The Discovery Center admits students of any race, religion, color, or national and ethnic origin.
NON-DESCRIMINATION POLICY: The Discovery Center admits students of any race, religion, color, national and ethnic origin.
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Please Select
Caucasian
African American
Asian/South Pacific
Native American
Hispanic
Other
Permissions:
I give permission for my child to go for a walking excursion on the church/school grounds. (A separate sign-off will be obtained for off-site/bussed field trips.)
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Please Select
Permission Granted
I give permission for my child to be videotaped and photographed during the school day. These may be used in in-house displays/bulletin boards. I understand I will be notified if any film/photos/video may be used for publication/marketing and I will sign a separate release to allow my child's image to be used in applications other than in-house formats.
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Please Select
Permission Granted
I give the program staff permission to use baby-wipes with my child. I understand that baby-wipes are used on occasion to clean hands before participating in a food-related experience, or on a field trip when a sink may not be readily available. In addition to using wipes in the classroom, I also give my permission for program staff to use baby-wipes in the bathroom, should my child's bottom need cleaning. (Wipes will be distributed by program staff and will be kept out of the reach of children.)
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Please Select
Permission Granted
I give permission for the health care consultant, licensing and accreditation agents to view my child's records when conducting on-site quality rating visits. I authorize the program staff to take whatever emergency medical measures necessary for the care and protection of my child. This may involve apply first aid, administering CPR, contacting 911 or Poison control for assistance. If professional medical assistance is required, emergency responders will transport to the nearest hospital; if possible, they will transport to the "hospital of choice" indicated on the child's emergency form.
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Please Select
Permission Granted
Program staff have my permission to apply sunscreen to my child if they are on-site for more than 3 hours and will be outside for longer than half an hour. I will notify staff of any special instructions regarding sunscreen and my child. I understand I can provide sunscreen labeled with my child's name if I have a brand preference.
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Please Select
Permission Granted
N/A, My child is younger than 6 months
Program staff have my permission to apply diaper cream to my child (if in diapers) when there is irritation and presence of a diaper rash. I will notify staff of any special instructions. I understand I can provide diaper cream labeled with my child's name if I have a brand preference.
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Please Select
Permission Granted
N/A, My Child does not wear pull-ups or diapers
In consideration of the changing/diapering of my child (for children in diapers or pull-ups), or assistance of my child in toileting (if training or independent), I fully recognize the element of risk involving equipment and exposure to bodily fluids. I assume all ordinary risks and necessary contact incidental to such care-taking and do hereby release and agree to hold harmless the program staff assisting my child. Neither program staff, nor any of the said persons, shall be held responsible for any injury or illness incurred as the direct or indirect result of this ordinary activity, but do not release responsibility for negligent or willful misconduct. There is no medical insurance provided by the preschool program. I have read this notice and understand all of its terms and accept its terms voluntarily and will full knowledge of its significance.
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Please Select
Permission Granted
I do not grant permission and do not wish for program staff to assist my child in the bathroom and in changing/diapering. I understand that I will be notified to come to the center and administer bathroom/diapering needs in person, and that my child will not be cleaned until I arrive, unless there is urine/fecal matter contaminating surfaces or classroom items. If this type of bathroom emergency occurs, I understand there will be two staff members present during my child's toileting/bathroom care.
The Parent Handbook is updated annually and parents will be notified and sent any updates to policy. Handbooks are emailed out to parents annually and are available upon request at anytime.
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I have received a Parent Handbook and/or understand that I can request a copy anytime.
Parent/Guardian Name
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Parent/Guardian Signature
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