Child's Name

First NameLast Name

Items Needed to Attend Care:

A well balanced healthy lunch: If you need suggestions on food items to send for your child please let us know and we would be happy to assist you.
A change of clothing: Please be sure to update as the seasons change.
Appropriate outside clothing for the season: i.e. jackets, snow suits, gloves, bathing suits ect
Rest time items: Mandatory fitted crib sheet (Infants: Fitted porta crib sized sheet) Infants under the age of 12 months are not permitted to use blankets in their crib, they may use a sleep sack.
- All children ages 5 and under who attend childcare for a full day are required to have a rest period. Please note that parents are responsible for laundering their child's bedding at least once per week. We ask that parents provide a washable bag to store/transport the bedding in
If your child is not potty trained: Diapers and wipes. If your child requires diaper cream, a topical medication form must be filled out before we can apply diaper cream.
If your child drinks bottles: They must come pre made. Children over 12 months of age should not drink from bottles.
Drink cups: Children should be provided with a drink for each meal/snack.

All items brought in from home must be labeled with your child's name. This includes jackets, lunchboxes, food containers, bottles, clothing, and all nap items. This is the only way to be sure that your child is taking home his or her personal items.

We encourage children to leave their personal toys at home. The staff are not responsible for any of your children's personal belongings

Please note that if your child does not have the appropriate items for the day a parent will be called to bring these items or pick up their child

Parent Signature*

Daily Routines

What is your child's bed time: *

Hour Minutes

AM/PM Option

What time does your child wake up:*

Hour Minutes

AM/PM Option

What are your child's normal meal times?
Breakfast Time Lunch Time Snack Time

Let us know more about your child: *

	Yes	No
Does your child sleep well?
Does your child nap?
Does your child need help eating?
Is your child toilet trained?
Is your child dry during rest time?
Does your child need help in the bathroom
Does your child need help dressing

List any other children who live in the home with your child name age relationship*

List any other adults that live in the home with your child name and relationship to child*

List any other school environments your child has attended and dates of attendance*

Please provide any additional information about your child: (infant families this is a great place to share more about their daily schedule)*

Parent Handbook:

I have received a copy of the Parent Handbook. I have been informed of, understand and agree to follow all of the policies and procedures as outlined in the Parent Handbook for Ballestrini's Child Care Center

ParentGuardian Signature*

Liability Waiver:

I hereby certify that my child(ren) is/are in good physical condition and do/does not suffer from any disability that prevents or limits his/her participation in all activities conducted by Ballestrini's. I acknowledge that Ballestrini's will not assume any responsibility or liability for personal injury or damages caused by the injury. In the event Ballestrini's is unable to reach a parent, guardian or any emergency contact, I hereby give permission for my child(ren) to be transported to the nearest hospital for treatment in case of an accident or emergency. I hereby further authorize(s) any of the staff or employees to provide for, approve and authorize health care at hospital.

ParentGuardian Signature*

Emergency:

I give permission to Ballestrini's Child Care Center to make whatever emergency measures necessary for the care and protection of my child while under the supervision of Ballestrini's Child Care Center. In case of a medical emergency, I understand that my child will be transported to the hospital by the local emergency unit for treatment, at my expense. In the event of an accidental ingestion, I understand that Ballestrini's Child Care Center will contact the Poison Control Center. I give my permission for the staff to do as told by the Poison Control Center. I hereby authorize the child care center to act on my behalf in case of emergency

ParentGuardian Signature*

Behavior Policy:

The behavior policies have been explained to me and I understand them. I also understand that the behavior policies are in the Parent Handbook, which I received a copy of and I can refer to this at any time with questions.

ParentGuardian Signature*

Photo Release:

I hereby grant and authorize Ballestrini's the right to take, edit, copy, publish, distribute and make use of any and all pictures or video taken of my child(ren) to be used in and/or for legally promotional materials and digital communications. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of Ballestrinis and will not be returned.

ParentGuardian Signature*

Cancellation & Refunds:

I understand that my child is enrolled at Ballestrini's Child Care Center. I agree that if I decide to withdraw my child, I will give two weeks written notice or be billed for the equivalent time. I further agree that if this goes into collections that I will be responsible for any additional cost incurred trying to collect the monies due to the center.

ParentGuardian Signature*

Food:

I give my child permission to eat and drink foods that are brought by staff and children for parties and special occasions. I, as a parent and or guardian will keep the staff informed of any food allergies as they or if they develop. This notification will be provided to the center and it must be in writing.

ParentGuardian Signature*

Walking Field Trip Permission:

I give my child permission to go on walks with the child care center at any given time. There will be no less than two or more staff present on each walking trip. Signing this form will authorize Ballestrini's Child Care Center to allow my child to participate in all future walking trips.

ParentGuardian Signature*

Tuition Payment:

Tuition payment is due on Friday for the following week of child care. There is an additional charge of $25 per week for any payment that is not made in advance of service. Child care services can be suspended due to non payment. Parent will set up tuition payment on the Procare app.

ParentGuardian Signature*

Personal belongings:

All items brought in from home MUST be labeled with your child's name. This includes, but is not limited to: jackets, lunchboxes, food containers, bottles, cups, clothing, and all nap items. This is the only way to be sure that your child is taking home his or her personal items. We encourage children to leave their personal toys at home. The staff are not responsible for any of your children's personal belongings. If your child does not have the appropriate items for the day a parent will be called to bring these items or pick up their child.

ParentGuardian Signature*

CHILDREN AGES 6 WEEKS - 6 YEARS : Ballestrini's Childcare Center has partnered with the Office of Early Childhood and the Sparkler App. You agree to download the sparkler app and fill out the The Ages and Stages Questionnaire (ASQ) prior to your child's first day of care. Each site has a special code to allow families to link with their child's teachers:

Waterford Ballestrini's: BCWaterford

Salem Ballestrini's BCSalem

Niantic Ballestrini's: BCNiantic

Potassium Iodide (KI)

Child Medication Authorization Form

Please complete a separate form for each child enrolled. It is suggested that you consult with your child's primary care physician before completing this form.

Name of Child: *

First NameLast Name

Date of Birth*

Date

Address*

Home Phone

Please enter a valid phone number.

Work phone

Please enter a valid phone number.

Name of ParentGuardian*

Childs Primary Care Physician*

Primary Care Phone

Please enter a valid phone number.

Please indicate your authorization or refusal by checking the appropriate box (es) below:*

NO, I do NOT want my above named child to be given KI by my provider in the event ofYES I want my above named child to be administered KI by my provider whenThe Governor declares a nuclear emergency, AND Individuals in a specific area, that includes this child care facility/youth camp, are advised by the Emergency Alert System (EAS) to take the Potassium Iodide (KI) tablets, AND I understand that the ingestion of Potassium Iodide (KI) under these circumstances is voluntary.pe option 2

I have been advised in writing by the facility about the contraindications and the potential side effects of taking Potassium Iodide. I understand that it is my responsibility to notify my provider in writing if I desire to change my authorization as indicated above.

ParentGuardian Signature*

Date*

Date

Public school transportation form

*Only to be used for children who require transportation from public school

Childs Name

Grade

Public school child attends

Program child will attend:

Before school onlyAfter school onlyBefore and after school

** School vacation care is only guaranteed for children enrolled in BOTH before and after care and is subject to additional charges. ** Children in BOTH before and after care are able to attend for all ONE DAY school closings at no attentional charge.

** Please note you must also contact your child's school or bus company to make sure the proper forms are fill out with them as well

Parent Signature

Items Needed to Attend Care:

Daily Routines

Policy Agreement and Permission

Parent Handbook:

Liability Waiver:

Emergency:

Behavior Policy:

Photo Release:

Cancellation & Refunds:

Food:

Walking Field Trip Permission:

Tuition Payment:

Personal belongings:

Potassium Iodide (KI)

Child Medication Authorization Form

Public school transportation form