The Goddard School of Chadds Ford

APPLICATION FOR ADMISSION

Emergency Contact - Parental / legal guardian consent form
Child's Name

First NameLast Name
Nickname
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Primary language
Gender:
School Age Child's School
Do Relevant Custody Papers Apply
Parent / Legal Guardian 1
Parent / Legal Guardian Name

First NameLast Name
Home: Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business: Name
Work Hours
Business Phone
Format: (000) 000-0000.
Business: Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Parent / Legal Guardian Name

First NameLast Name
Home: Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business: Name
Work Hours
Business Phone
Format: (000) 000-0000.
Business: Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
EMERGENCY CONTACT TO WHOM THE CHILD MAY BE RELEASED TO IN THE EVENT OF EMERGENCY

Emergency Contacts

Rows	Full Name	Full address	Relationship	Phone number when child is in school
1.
2.
3.

Child's Physician/Medical Care Provider
Hospital Affiliation
Physician Phone
Format: (000) 000-0000.
Child's Physician/Medical Care Provider: Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Child's Dentist
Dentist Phone Number
Format: (000) 000-0000.
Disabilities or Additional Support Needs
Allergies (including medication reaction)
Medical or Dietary Information Necessary in an Emergency Situation
Medication, Special Conditions
Health Insurance info for Child or Medical Assistance Benefits
Policy Number (required)
PARENT'S / LEGAL GUARDIAN SIGNATURE IS REQUIRED TO INDICATE CONSENT
Signature - Obtaining Emergency Medical Care
Signature - Administration of Minor First-Aid Procedures
In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the child care facility to have your child transported to the hospital.
Signature of parent/legal guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

NEW START QUESTIONNAIRE—ALL ABOUT ME!
1) My Name is...

First NameLast Name
2) My friends and family sometimes call me...
3) When I feel sad, makes me feel better* can make me feel better.
4) When I am happy, I like to to when I'm happy* and I love to play with love to play with*
5) My favorite snack is favorite snack* and my favorite song is favorite song* .
6) Be careful, I'm allergic to allergic to* and I really don't like I don't like .
7) At home, my family speaks language* .
8) I may need accommodations to help with communication
9) When I was born, I was ....
10) Any other information/concerns you'd like us to be aware of:
Parent/Guardian/Mom Birthday (year not needed):
Parent/Guardian/Dad Birthday (year not needed):

PASSWORD FORM
It is part of The Goddard School® security policy to have a password that is given to anyone whom you designate as an authorized pick-up for your child. Your child will be released to this authorized person only if the following conditions have been met:
1. The Director must be notified in writing, either at the time of enrollment, or before the pick-up, that you are authorizing someone other than yourself to pick-up your child. If you telephone the school to authorize a pick-up, be prepared to receive a return phone call to verify the information.
2. At the time of notification, you will need to give us the authorized individual's full name and his/her approximate time of arrival so we can then notify the staff.
3. The authorized individual must show a state issued photo ID and tell the Owner or Director the password you have designated below.
4. The authorized individual will be responsible for signing your child out of the building.
The password is an added measure of security for your family and will be kept with your child's emergency information.
Child's Full Name

First NameLast Name
Password
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

PHOTO/VIDEO PERMISSION
CONSENT TO PHOTOGRAPH/VIDEO
For value received and without additional consideration, I consent to The Goddard School®, Goddard Systems, LLC, and Goddard Franchisor, LLC (as manager and franchisor of The Goddard School franchise system, respectively) taking photographs and videos of my child(ren), and using all such photographs and videos in the manner selected and described below only and for no other purpose:
CHILD(REN'S) NAME(S)
Child's Full Name

First NameLast Name
CHECK ONE
Full Use = illustration, advertising, training, and publicity in any manner or form, including press releases, broadcast, print, digitál, electronic and social media, and for In-House purposes (described below)
In-House Only = posted in classroom/hallways, shared with other classroom families in print/electronic newsletters and communications, and sent to child's parents through electronic daily report tools, such as Goddard Family Hub, Wonder of Learning Hub (Kaymbu), Tadpoles or Preschool2Me.
Family Only = sent only to child's parents/guardians through electronic daily report tools, such as Goddard Family Hub, Kaymbu, Tadpoles or Preschool2Me.
PLEASE NOTE: Although we have a School policy against it, it is possible for individuals who receive group photos in electronic daily activity reports to share these group photos through their personal social media accounts, which may include your child's image. By selecting "In-House Only", you acknowledge this possibility and that we cannot control every subsequent use of group photos shared with other Goddard School families.
AGREEMENT NOT TO POST PHOTOS OF OTHER CHILDREN
I agree that I will not post or use any photographs or videos that I receive from or take at The Goddard School that include children other than my own child(ren) in print, electronic or social media or any other form. This includes group photos that I receive as part of an electronic daily activity report. My agreement extends to photos or videos taken by any member of my family or any visitors that I bring to The Goddard School.
Signature of Parent/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

OUTSIDE ENGAGEMENTS RELEASE & WAIVER (Parents)
THIS IS A RELEASE AND WAIVER OF LIABILITY (“Release”) made this date Date* ,by parents/legal guardians First Name* Last Name* (“Parents”) in favor of the releasees identified below.
BACKGROUND
Parents have engaged The Goddard School (the “School”) to provide child care services for their child[ren], First Name* Last Name* (“Student”). Parents have requested that one or more employees of the School (the “Employee”) be permitted to transport Student in a private vehicle to and/or from the School on certain days (“Private Transport Services”) and/or provide child care services for Student outside of the School premises during Employee’s non-working hours (“Off-Site Child Care Services”).
The School desires to clarify the relationship among the parties.
AGREEMENT
NOW, THEREFORE, with the Background section incorporated by reference, in consideration of the agreements and covenants contained in this Agreement and for other good and valuable consideration, the receipt and sufficiency of which are acknowledged, and intending to be legally bound, Parents agree as follows:
1. Parents acknowledge that they have requested that Employee provide Private Transport Services and/or Off-Site Child Care Services solely for Parents’ convenience and benefit, and not for the convenience or benefit of the School.
2. Parents acknowledge that, in providing Private Transport Services and/or Off-Site Child Care Services, Employee is acting as an independent contractor and not as an employee of the School. Parents acknowledge that providing Private Transport Services and/or Off-Site Child Care Services is not part of Employee’s job with the School and that the School is not requesting that Employee provide these services.
3. Parents acknowledge that the School is not responsible to pay any salary or expenses, or to withhold any taxes, associated with Employee’s provision of Private Transport Services and/or Off-Site Child Care Services.
4. Parents acknowledge that the School has not reviewed Employee’s driving record and makes no representations regarding Employee’s driving history or ability or the existence or scope of Employee’s insurance. Parents further acknowledge that any Private Transport Services and/or Off-Site Child Care Services would be provided in a vehicle and/or on premises that are not owned or insured by the School; the School makes no representation regarding the safety or reliability of any vehicle or premises used by Employee in providing Private Transport Services and/or Off-Site Child Care Services.
5. Parents release and forever discharge The Goddard School, its franchisor, and their affiliates, and the present and former owners, employees, officers, shareholders, directors, agents, attorneys, servants, representatives, parents, subsidiaries, insurers, affiliates, heirs, successors and assigns of The Goddard School and GSL, respectively, in both their individual and corporate capacities ("Releasees") from any and all liability, causes of action, claims or demands of any kind, arising in law or equity (including but not limited to death or serious bodily injury to Student and/or others) relating to or arising from the provision of Private Transport Services and/or Off-Site Child Care Services by Employee.
6. Parents further agree to defend, indemnify and hold Releasees harmless from any liability, loss, costs or expenses, including attorneys' and consultants' fees, relating to or arising from the provision of Private Transport Services and/or Off-Site Child Care Services by Employee.
7. Parents further agree that if any of them make any claim or demand of any kind or institute any complaint or action, at law or in equity, in any forum, against any of the Releasees relating to or arising from the provision of Private Transport Services and/or Off-Site Child Care Services by Employee, they shall be liable for all costs and expenses, including attorneys' and consultants' fees, incurred by the Releasees in connection with the claim, demand, complaint or action.
8. Parents' obligations under this Release shall be joint and several.
9. This Release supersedes and replaces all prior negotiations and all agreements proposed or otherwise, whether written or oral, concerning all subject matters covered in this Release.
10. Parents execute this release on behalf of themselves and any person claiming by, under or through them, including but not limited to their dependents, heirs, executors, administrators, assigns and successors.
11. Parents acknowledge that they have had the opportunity to consult with counsel of their choosing before executing this Release.
12. If one or more of the provisions of this Release shall for any reason be held invalid, illegal or unenforceable in any respect, such invalidity, illegality or shall not affect or impair any other provision of this Release. This Release shall be construed as if such invalid, illegal or unenforceable provisions had not been contained in this Release.
I HAVE READ THIS AGREEMENT AND UNDERSTAND ITS TERMS. I WOULD NOT SIGN THIS AGREEMENT IF I DID NOT UNDERSTAND AND AGREE TO BE BOUND BY ITS TERMS.
Signature of Parent/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

MEDICAL TRANSPORTATION WAIVER
The undersigned authorizes representatives of The Goddard School® to contact Emergency Medical Technicians to transport ("Student") to receive medical care, if such transportation/care is deemed necessary.
The undersigned irrevocably release any claims, demands, actions or causes of action against “The Goddard School, its franchisor, and their affiliates” and their respective representatives and employees, which arise out of or relate to the transportation of Student and any medical care provided.
This authorization and waiver shall remain effective until Student withdraws from The Goddard School®
Signature of Parent/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

PROCEDURES FOR REFERRAL TO INTERVENTION SERVICES
Based on our teacher observations and educational assessment tools, there are incidences where a teacher may feel it would benefit a child to receive intervention services to support and further their development. If such a case arises, it is our procedure to conference with parents and work together to determine the best course of action, which may include accessing services available through the Chester County Intermediate Unit or other health specialists. Please note that no intervention or outside services are contacted without written parental consent.
INDIVIDUALIZED EDUCATION PLANS (IEP) & INDIVIDUALIZED FAMILY SERVICE PLANS (IFSP) REQUEST
Child's Full Name

First NameLast Name
Your child's growth and development is measured with developmental assessments. If you child currently has an IEP/IFSP, it would be beneficial to share a copy of this plan with us so we can work together to ensure that the guidelines are put into practice. You do not have to provide this information if you do not wish to do so.
Signature of Parent/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name
LANGUAGE ACCOMMODATIONS
Children whose first language isn't English are encouraged to use home language, gestures, communication devices, sign language, and pictures to communicate when needed.
RELEASE OF CHILD FILES
The Goddard School, Exton is happy to transfer your child's record to another education setting with written request from parent or legal guardian with complete contact and mailing information. Records Include: most recent progress report and most recent health assessment on file.

SECURITY CAMERA/VIDEO FOOTAGE RELEASE
I understand that The Goddard School® has installed security cameras in the foyer and around the outside perimeter of the building. I also understand that while attending The Goddard School®, my child may be videotaped by a security

I recognize that I may also be videotaped by a security camera while at or around premises. I will notify each person listed on the Application for Admission that he or she may be also videotaped while at or around the school premises.
Signature of Parent/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

ADDENDUM TO EMERGENCY CONTACT FORM
The Goddard School, located in Chadds Ford PA, is not responsible for providing transportation to or from the school other than in the event of medical emergencies. Parents sign a separate form solely for emergency medical transportation. This is an addendum to that form. The Goddard School of Chadds Ford does not ever permit walking excursions, swimming, or wading. We are however required by PA Code Chapter 3270.182(6) to have parents sign and store in the child's file a form that states that, "A child's record shall contain signed parental consent for transportation, walking excursions, swimming, or wading."
Signature - Obtaining Emergency Medical Care
Signature- Administration of Minor First-Aid Procedures
Signature- Walks and Trips
Signature - Swimming
Signature- Transportation by the Facility
Signature - Wading

NON-DISCRIMINATION IN SERVICES POLICY STATEMENT
Subject: Non-Discrimination in Services Policy Statement
To: Parents
From: Vincent Capodanno Onsite Owner
Admissions, the provisions of services, and referrals of clients shall be made without regard to race (to include hair type, hair texture, or hair style), color, religious creed (to include all aspects of religious observances and practice, as well as belief), disability, ancestry, national origin (including Limited English Proficiency), age (40 and over), or sex (to include pregnancy status, childbirth status, breastfeeding status, sex assigned at birth, gender identity or expression, affectionate or sexual orientation, and differences in sex), and retaliation. Program services shall be made accessible to eligible persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to, equipment redesign, the provision of aides and the use of alternative service delivery locations. Structural modifications shall be considered only as a last resort among available methods. Any individual/client/patient/student (and/or their guardian) who believes they have been discriminated against, may file a complaint of discrimination with:
Facility Contact Information
The Goddard School
2 Hillman Drive
Chadds Ford, PA 19317
Email: chaddsfordpa@goddardschools.com
Phone: 610-358-0380
Office for Civil Rights
U.S. Department of Health and Human Services
Centralized Case Management Operations
200 Independence Avenue, S.W.
Room 509 HHH Bldg
Washington, D.C. 20201
Customer Response Center: (800) 368-1019
TDD: (800) 537-7697
https://www.hhs.gov/ocr/complaints
Email: ocrcomplaint@hhs.gov
(Within 180 days from the date of incident)
Commonwealth of Pennsylvania
Department of Human Services
Bureau of Equal Opportunity
Room 225, Health & Welfare Building
P.O. Box 2675 Harrisburg, PA 17120
Inquiries: (717) 787-1127
Email: RA-PWBEOAO@pa.gov
(Within 90 days from the date of incident)
Pennsylvania Human Relations Commission
333 Market Street, 8th Floor
Harrisburg, PA 17101
https://www.phrc.pa.gov/Complaints/Pages/How-to-File-a-Complaint.aspx
Inquiries: (717)787-4410
TTY users only: (717) 787-7279
(Within 180 days from the date of incident)
Signature of Parent/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

APPLICATION FOR ADMISSION

Parent / Legal Guardian 1

EMERGENCY CONTACT TO WHOM THE CHILD MAY BE RELEASED TO IN THE EVENT OF EMERGENCY

PARENT'S / LEGAL GUARDIAN SIGNATURE IS REQUIRED TO INDICATE CONSENT

NEW START QUESTIONNAIRE—ALL ABOUT ME!

PASSWORD FORM

PHOTO/VIDEO PERMISSION

CONSENT TO PHOTOGRAPH/VIDEO

CHILD(REN'S) NAME(S)

AGREEMENT NOT TO POST PHOTOS OF OTHER CHILDREN

OUTSIDE ENGAGEMENTS RELEASE & WAIVER (Parents)

BACKGROUND

AGREEMENT

MEDICAL TRANSPORTATION WAIVER

PROCEDURES FOR REFERRAL TO INTERVENTION SERVICES

INDIVIDUALIZED EDUCATION PLANS (IEP) & INDIVIDUALIZED FAMILY SERVICE PLANS (IFSP) REQUEST

LANGUAGE ACCOMMODATIONS

RELEASE OF CHILD FILES

SECURITY CAMERA/VIDEO FOOTAGE RELEASE

ADDENDUM TO EMERGENCY CONTACT FORM

NON-DISCRIMINATION IN SERVICES POLICY STATEMENT