Harding 2023-24 Afterschool Childcare Registration Form

Registrations on Hold

Thank you for your interest in the City of El Cerrito's childcare programs! Childcare begins on Monday, August 21, 2023. Because staff is focused on ensuring a smooth start of program, new registrations are temporarily on hold. We will respond to new requests as soon as possible. Please keep in mind that completing this form does not automatically enroll your child into our program. Thank you!
Afterschool Childcare Registration Form: 2023-24 School Year

Please take your time and submit this form only when you are certain of your choices. This form will act as a binding registration agreement if a spot is available for your child.
A Note About This "SmartPDF" Form

This "SmartPDF" Form inputs information on to several different State mandated Child Care Licensing Forms. The fields below are essentially verbatim of the language on these forms and can be confusing. Please contact us if you have any questions. Many of the State forms require you to input some of the same information that you have previously provided. We apologize for this duplication of effort, but we believe that this is the easiest way for customers to fill out the required information that will then be transposed on to the forms as required by the State. Thank you for your understanding!
Please upload a recent photo of your child.*

Please provide a close up photo of your child's face. Please make sure that it is clearly visible. Photos are collected for emergency situations only.
Cancelof
Child's School*
Only one school is listed. If it is not your child's school, please go back to www.el-cerrito.org/childcare and choose a different school.
Child's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Child's Birthday
Child's Grade in Fall 2023*

Transitional KindergartenKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th grade
6 Digit Registration Receipt Number*
Before completing this form, please pay the registration fee online and enter your receipt number here. Details: www.el-cerrito.org/childcare
Student Information (Does your child have any special needs such as developmental differences, physical limitations or dietary restrictions that may affect their experience?)*
Parent/Guardian First Name 1*
Parent/Guardian Last Name 1*
Cell Phone Parent/Guardian 1*
Please enter a valid phone number.
Email Parent/Guardian 1*
Please note, this email will be used for all confirmations related to this form packet.
Parent/Guardian First Name 2
Parent/Guardian Last Name 2
Email Parent/Guardian 2
example@example.com
Cell Phone Parent/Guardian 2
Please enter a valid phone number.
Type a question
My child is registered to attend Harding for the 2023-24 School Year*

Yes (required for registration)No (will not be registered but placed on interest list)I am not sure what school my child will be attending (will not be registered but placed on interest list)
My child is up to date with vaccinations for COVID-19*

YesNoIn ProgressDecline to State
For the grids below, please only choose 1 Afterschool Care grid. Grids that do not apply to your child's grade can be skipped.

I need Afterschool Care for a Transitional Kindergarten or Kindergarten student.

NOTE: Care prices are based on bell schedules that could change. Changes in bell schedules may affect pricing. Submitting this form is a financial agreement committing you to these payments.

I understand that if I qualify for a reduced rate, I am responsible for the fees below until I am approved. Childcare Discount Applications are due within 48 hours of your registration.

I understand the pricing is based on 10 equal payments of the annual fee (regardless of number of school days in a particular month), of the fees listed below, Aug 15-May 15 and is as follows:

1) Care for 5 days per week is $741 per payment

2) Care for 4 days per week is $652 per payment

3) Care for 3 days per week is $534 per payment

4) Care for 2 days per week is $385 per payment

If Transitional Kindergarten (TK) Release Time is before Kindergarten (currently only at Harding School) then the following fees will apply:

1) Care for 5 days per week is $788 per payment

2) Care for 4 days per week is $693 per payment

3) Care for 3 days per week is $567 per payment

4) Care for 2 days per week is $410 per payment

Requested Schedule for TK or Kindergarten Students (5 days per week requests will be prioritized).

	Monday	Tuesday	Wednesday	Thursday	Friday
TK Afterschool Childcare (Dismissal until 6pm)
Kindergarten Afterschool Childcare Dismissal until

I need Afterschool Care for a for a 1st through 6th grade student.

NOTE: Care prices are based on bell schedules that could change. Changes in bell schedules may affect pricing. Submitting this form is a financial agreement committing you to these payments.

I understand the pricing is based on 10 equal payments of the annual fee (regardless of number of school days in a particular month), of the fees listed below, Aug 15-May 15 and is as follows:

1) Care for 5 days per week is $646 per payment

2) Care for 4 days per week is $568 per payment

3) Care for 3 days per week is $465 per payment

4) Care for 2 days per week is $336 per payment

Requested Schedule for 1st through 6th Grade Student (5 days per week schedules will be prioritized).

	Monday	Tuesday	Wednesday	Thursday	Friday
1-6th Grade Afterschool Childcare (Dismissal through 6pm)

Payment, Cancellation and Schedule Change Policies: I have read the payment, cancellation and schedule change policies in the Parent Handbook (www.el-cerrito.org/childcare) and I understand the procedures and requirements including:

Payments: billing cycles, automatic payments, and program billing.
Program Cancellation: no cancellation period of August 1 to October 11, 2023; cancellation deadlines and effective dates; no cancellations after the April 3, 2024 deadline; and the cancellation fee.
Schedule Changes: no schedule reductions until October 12, 2023; schedule change deadlines and effective dates; no schedule reductions after the April 3, 2024 deadline; and the schedule change fee.

I agree to the payment, cancellation and schedule change policies and procedures listed in the in the Parent Handbook and summarized above. I understand that policies are subject to change at any time.
Signature*

Clear
Photo Release: I agree to have photographs, films, or tape recordings taken of me or minor child registered under my signature while participating in City of El Cerrito programs and I permit these photographs, film or tapes to be released for use in publications, promotional materials, web site, and for other public information purposes by the City of El Cerrito.
Signature*

Clear
Behavior Policy: I understand that my child is expected to follow all rules established by his or her instructor, and any failure to comply may result in dismissal from the program. I also understand that no refunds will be given. A copy of our policy is in the Parent Handbook.
Signature*

Clear
Parent Handbook: I understand it is my responsibility to fully review the Parent Handbook and all other policies for the program and follow them accordingly.
Signature*

Clear
IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES

California Department of Social Services - Form LIC 700
To Be Completed by Parent or Authorized Representative
Child's Name*

Last NameMiddle NameFirst Name
Sex*
Phone Number Most Associated with Child*
Please enter a valid phone number.
Address Most Associated with Child*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Birth Date*

MonthDayYear
Date
Parent 1/Authorized Representative 1 Name*

First NameMiddle NameLast Name
Business/Cell Telephone 1
Please enter a valid phone number.
Home Phone 1*
Please enter a valid phone number.
Home Address 1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2/Authorized Representative 2 Name

First NameMiddle NameLast Name
Business/Cell Phone Number 2
Please enter a valid phone number.
Home Phone Number (if different)
Please enter a valid phone number.
Address 2 (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person Responsible for Child (One Person or can write: First Name "Both" Last Name "Parents/Guardians")*

First NameLast Name
Home Phone Number*
Please enter a valid phone number.
Business/Cell Phone Number
Please enter a valid phone number.

Additional Persons Who May Be Called in an Emergency*

	Name	Address	Telephone	Relationship
First Person
Second Person
Third Person
Fourth Person

PHYSICIAN AND DENTIST TO BE CALLED IN AN EMERGENCY*

	Name	Address	Medical Plan and Number	Telephone
Physician
Dentist

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?*

Call Emergency HospitalOther

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (Child will not be allowed to leave with any other person without written authorization from parent or authorized representative)*

	Name	Relationship
First Person
Second Person
Third Person
Fourth Person
Fifth Person

Signature of Parent/Guardian/or Authorized Representative*

Clear
Date*

MonthDayYear
Date of Signature
CHILD'S PREADMISSION HEALTH HISTORY -PARENT/AUTHORIZED REPRESENTATIVE REPORT

California Department of Social Services - Form LIC 702
Child's Name*

First NameMiddle NameLast Name
Sex*
Birthdate*

MonthDayYear
Date
Parent/Authorized Representative Name*

First NameMiddle NameLast Name
Does Parent/Authorized Representative Live In Home With Child?*
Parent 2/Authorized Representative 2 Name

First NameMiddle NameLast Name
Does Parent/Authorized Representative Live In Home With Child?
Is/Has Child Been Under Regular Supervision of Physician?*
Date of Last Physical/Medical Examination*

Past Illnesses-Check illnesses that child has had and specify approximate dates of illnesses:

	Mark with "X" to indicate illness	Date
Chicken Pox
Asthma
Rheumatic Fever
Hay Fever
Diabetes
Epilepsy
Whooping Cough
Mumps
Poliomyelitis
Ten-Day Measles (Rubeola)
Three-Day Measles (Rubella)

Specify Any Other Serious or Severe Illnesses or Accidents
Does Child Have Frequent Colds?*

YesNo
How Many Colds in the Last Year?
List Any Allergies Staff Should be Aware of:
DAILY ROUTINES

Diet Pattern*

	What does child usually eat for these meals?
Breakfast
Lunch
Dinner

What Are Usual Eating Hours?*

	When are these meals usually served?
Breakfast
Lunch
Dinner

Any food Dislikes?*
Any Eating Problems?*
Parent/Authorized Representative Evaluation of Child's Health (i.e. healthy, frequent ear aches, etc.)*
Is Child Presently Under A Doctor's Care?*

YesNo
If Yes, Name of Doctor
Does Child Take Prescribed Medication(s)?*

YesNo
If Yes, What Kind And Any Side Effects?
Does Child Use Any Special Device(s)?*

YesNo
If Yes, What Kind?
Does Child Use Any Special Device(s) At Home?*

YesNo
If Yes, What Kind?
Parent/Authorized Representative Evaluation of Child's Personality*
How Does Child Get Along With Parent/Authorized Representative, Brothers, Sisters And Other Children?*
Has the Child Had Group Play Experiences?*
Does The Child Have Any Special Problems/Fears/Needs? (Explain)*
What Is The Plan For Care When The Child Is Ill?*
Reason for Requesting Day Care Placement?*
Signature*

Clear
Date*

MonthDayYear
Signature Date
CONSENT FOR EMERGENCY MEDICAL TREATMENT - Child Care Centers Or Family Child Care Homes

California Department of Social Services - Form LIC 627
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO HARDING CHILDCARE & SCHOOL AGE PROGRAMS TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN(M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S) FOR First Name* Last Name* . THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE.
Facility Name
Child Has The Following Medication Allergies:
Signature*

Clear
Date*

MonthDayYear
Signature Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
CHILDCARE CENTER - NOTIFICATION OF PARENTS' RIGHTS

California Department of Social Services - Form LIC 995
As a Parent/ Authorized Representative, you have the right to:

1. Enter and inspect the child care center without advance notice whenever children are in care.

2.File a complaint against the licensee with the licensing office and review the licensee's public file kept by the licensing office.

3.Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years.

4.Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order.

6. Receive from the licensee the name, address and telephone number of the local licensing office.

Licensing Office Name: California Childcare Licensing - Oakland Regional Office

Licensing Office Address: 1515 Clay Street, Suite 1102 Oakland, CA 94612

Licensing Office Telephone #: (510) 622-2602

7. Be informed by the licensee, upon request, of the name and type of association to the childcare center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office.

8. Receive, from the licensee, the Caregiver Background Check Process form.

NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE.

For the Department of Justice "Registered Sex Offender"database, go to www.meganslaw.ca.gov
Licensing Office Name
Licensing Office Address
Licensing Office Telephone Number
ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS' RIGHTS

(Parent/Authorized Representative Signature Required)
I, the parent/authorized representative of Child's Full Name*   have received a copy of the "CHILD CARE CENTER NOTIFICATION OF PARENTS' RIGHTS" and the CAREGIVER BACKGROUND CHECK PROCESS form from the licensee.
Name of Child Care Center: Harding Childcare & School Age Programs

Signature*   Date*
NOTE: This Acknowledgement must be kept in child's file and a copy of the Notification given to parent/authorized representative.

For the Department of Justice "Registered Sex Offender"database go to www.meganslaw.ca.gov
Facility Name
PERSONAL RIGHTS - Childcare Centers

California Department of Social Services - Form LIC 613A
Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.

(a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.

(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child.

(6) Not to be locked in any room, building, or facility premises by day or night.

(7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency.

THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

California Department of Social Services - Community Care Licensing

1515 Clay Street, Suite 1102

Oakland, CA 95814

(510) 622-2602
Name
Address
City
Zip
Area Code/Telephone Number
TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE:
Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:

ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the California Code of Regulations, Title 22, at the time of admission to:

Facility - Harding Childcare & School Age Programs

Address - 7115 C Street, El Cerrito, CA 94530
Name of Facility
Facility Address
Print Name of Child*

First NameMiddle NameLast Name
Signature of Representative/Parent/Guardian*

Clear
Title of Representative/Parent/Guardian*
Date*

MonthDayYear
Signature Date
Quick Reminders Before you Submit:

Please double check that the email listed for "Email Parent/Guardian 1" at the beginning of this document is correct. This is where confirmation of the submitted form will be sent. Please also ensure that once you hit "Submit" below, you are sent to a confirmation screen. If the screen does not change, look through this document for areas marked in red that are required to be completed before the document can be submitted.
Should be Empty:

Registrations on Hold

Afterschool Childcare Registration Form: 2023-24 School Year

A Note About This "SmartPDF" Form

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES

To Be Completed by Parent or Authorized Representative

CHILD'S PREADMISSION HEALTH HISTORY -PARENT/AUTHORIZED REPRESENTATIVE REPORT

DAILY ROUTINES

CONSENT FOR EMERGENCY MEDICAL TREATMENT - Child Care Centers Or Family Child Care Homes

CHILDCARE CENTER - NOTIFICATION OF PARENTS' RIGHTS

ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS' RIGHTS

PERSONAL RIGHTS - Childcare Centers

TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE:

Quick Reminders Before you Submit: