Application Form 2019 2020

FOR OFFICE USE ONLY

Application _________________ Admission Date __________________Date Received _________________ Class __________________

If you wish to register your child kindly complete all the required documents and submit them to the ECC with a -one time- nonrefundable registration fee of $56

ATTACHMENTS

Please make sure to attach the following when submitting the application to the ECC

1 One recent passport-size photo (taken within the past six months)2 photocopy of the childrsquos identity card or passport3 A Family record ( عائلي قيد (اخراج4 Photocopy of the parents ID ( both parents) 5 Photocopy of your childrsquos vaccine record

CHILD INFORMATION

Name in English (as in official documents)

_____________________________ _______________________________ _____________________________ (First) (Father) (Family)

Name in Arabic (as in official documents)

_____________________________ _______________________________ _____________________________ ( العائلة (إسم ( ) (( األول اإلسم األب إسم

Gender Male 1048709 Female 1048709

Date of Birth ______________________ _______________________ ______________________

Place of Birth ______________________ _______________________ (City) (Country)

Nationality(ies) ______________________ _______________________ ______________________

Home Address ______________________ _______________________ ______________________(Current address) (Street) (Building) (Floor)

______________________ ______________________ (Area) (city)

Home Phone(s) ______________________ _______________________

Please attach 1recent passport- size photo here

FAMILY INFORMATION

Motherrsquos maiden name ______________________________________________________________

Date of birth ______________________ _______________________ ______________________ (Day) (Month) (Year)Degrees completed ________________________________School University __________________

Email Address _______________________________________________________________

Name of Employer ______________________________ Title _________________________

Address ____________________________ MOF (required) المالي _________________الرقم

Business Phone _________________________ Cell Phone __________________________

Email Address _______________________________________________________________

Fatherrsquos Full Name _______________________________________________________________

Date of birth ______________________ _______________________ ____________________ (Day) (Month) (Year)

Degrees completed ________________________________School University __________________

Name of Employer ______________________________Title _____________________________

Address ____________________________ MOF (required) المالي _____________________الرقم

Business Phone _________________________ Cell Phone __________________________

Email Address _______________________________________________________________

Parents are 1048709 Living Together (with the child) 1048709 Divorced Separated (child living with ____________)

1048709 Other Specify ________________ ________________

Child Custody Information (If Applicable)Name of parent or guardian who has legal custody of the child ___________________________

Name(s) of parent(s) or guardian(s) who isare allowed to pick up the child from the ECC

_____________________________ _______________________________

Custody access restrictions (if applicable) _____________________________________________________________

2

If there is a Custody Order or any other Order in place that pertains to the custody andor access of the child a certified copy of the Order(s) is to be attached to this form

EMERGENCY CONTACT

In case of an emergency please specify the authorized people to be contacted

Full Name Relationship to the Child

Cell Phone

1

2

3

4

5

RELEASE INFORMATION

Please provide the following information about the people who are authorized to pick up your child from the ECC

Full Name Relationship to the Child

Cell Phone

1

2

3

4

5

PERSONAL DATA

Childrsquos Name in English (as in official documents)

_____________________________ _______________________________ _____________________________ (First) (Father) (Family)

3

Number of siblings at home _____________ Position of the child in the family _____________

Siblingrsquos Name Age Daycare School Attending (If Applicable)

1234

PREVIOUS CHILDCARE EXPERIENCE

Has your child been enrolled in any childcare previously If yes please specify for how long ________________________________________________________________________________________________

Please describe your childrsquos previous childcare experience (if applicable)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LANGUAGES ACTIVITIES

Language(s) spoken at home _____________________ _____________________ _____________________

Other language(s) that the child is exposed to _____________________ _____________________

Please list some activities that you do with your child (at home and outside)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How often do you read to your child ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC

Parentrsquos Name ______________________________ Parentrsquos Signature ______________________________

Date ______________________________

4

Medical Record Form 201_ 201_

Must be returned on your childrsquos first day at the ECC

CHILD INFORMATION

Name _________________________ _________________________ _________________________ (First) (Father) (Family)

Gender Male 1048709 Female 1048709 Blood Type _____________________

Date of Birth _________________________ _________________________ _________________________ (Day) (Month) (Year)

Home Phone(s) _________________________ _________________________

HEALTH HISTORY

Please check if the child has or may have had any of the following__ Abnormal bleeding bruising __ Dislocation (shoulder etc) __ Scarlet Fever__ Anemia __ Ear Problems __ Seizures__ Asthma __ Eye or Vision Problems __ Speech Problems__ Chicken Pox __ Hepatitis __ Tonsillitis__ Convulsions __ Measles __ Tuberculosis__ Diabetes __ Mumps __ Other__ Diphtheria __ Pneumonia

If any of the above is checked please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Did the child have any previous operation andor severe injury If yes please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SIGNIFICANT PROBLEMS

Does the child have any medical condition about which the ECC should be informed If yes please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is the child taking any medication If yes please list ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5

Please list any drug food beverage that the child is allergic to ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have a physical disability If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have any special medical problem requiring limitations on hisher physical activity If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IMMUNIZATIONSPlease indicate the last date of vaccination for the following

Required by the Ministry of Public Health in LebanonHepatitis BPolio Diphtheria Pertusis Tetanos Hemophilus Measles Mumps Rubella (MMR)Tuberculin test (PPD)RecommendedRota VirusPneumococcusMeningococcusHepatitis AChickenpox Varicella OptionalBCG (Tuberculosis) ndash OptionalTyphoid ndash Optional

Physicianrsquos Name _________________________ Physicianrsquos Signature __________________________Physicianrsquos Number(s) _________________________ _________________________Date ____________________

Medical Consent Form

In the event that my child __________________________________ becomes ill or sustains an injury while attending the ECC I give permission to the ECC nurse to administer First Aid I consent to a medical diagnosis and treatment as well as any medications necessary while under the care of the nurse I do understand that this form will apply to all future emergency situations and a copy of this form is as valid as the original This consent form will remain in effect throughout the academic year

Parentrsquos Name ___________________________ Parentrsquos Signature ___________________________

6

Date ___________________________

HEALTH INFORMATION

Name of Childrsquos Physician ___________________________________________

Work Phone _______________________ Cell Phone _______________________

Childrsquos Medical History

Type of Birth 1048709Normal 1048709 Premature 1048709 Specific Complications _________________________________________

Does the child have any medical condition about which the ECC should be informed________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Childrsquos Allergies Food Intolerance

Please list your childrsquos allergies andor food intolerance problems________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SLEEPING EATING AND TOILETING HABITS

When does your child go to bed ________________ When does your child wake up ________________

Does your child have any sleeping disturbances 1048709Yes 1048709 No If yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child feed himselfherself 1048709Yes 1048709 No

Do you have any specific concern regarding your childrsquos eating habits 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is your child toilet trained 1048709Yes 1048709 No 1048709 In the process

7

BEHAVIOR

Does your child show any aggressive behavior (kicking biting hitting yelling etc) 1048709Yes 1048709 No If yes please specify ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please explain what disciplinary measures you use with your child to deal with that________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child show any particular behavior which requires special attention at school (fear jealousy whining speech difficulty etc) 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child have temper tantrums 1048709Yes 1048709 No If yes please specify how often and how you deal with that ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What reward techniques (if any) do you use with your child at home to reinforce a positive behavior ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What makes your child angry sad andor anxious What makes your child happy Please give some specific details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8

GENERAL INFORMATION

Please indicate any other information you would like to share about your childfamily________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC I also agree to inform the ECC if there are any changes in the family relationship including any changes to the custodyaccess of my child

Parentrsquos Name ____________________________ Parentrsquos Signature ____________________________

Date ____________________________

9

Photography Consent Form

As part of the documentation process of childrenrsquos work the ECC teacherrsquos take photographs and videos of children in action as they participates in completing projects in the classrooms We would like to indicate below what uses of images of your child you are willing to consent toWe will only use the photographs in ways you agree to In any use of these images names and other personal information will NOT be identified at all

Images of my child may be used on ECCrsquos bulletin boards classroom displays and Life Cubby

Images of my child may be used as part of the LAU and ECCrsquos pamphlets brochures and information booklets

Images of my child may be used on the LAU and ECClsquos website and social media accounts

Please do not use any images of my child in any way

Please sign and return to the ECC

Name of the child

Parentrsquos Name

Relationship to the child

Signature Date

10

FAMILY INFORMATION

Motherrsquos maiden name ______________________________________________________________

Date of birth ______________________ _______________________ ______________________ (Day) (Month) (Year)Degrees completed ________________________________School University __________________

Email Address _______________________________________________________________

Name of Employer ______________________________ Title _________________________

Address ____________________________ MOF (required) المالي _________________الرقم

Business Phone _________________________ Cell Phone __________________________

Email Address _______________________________________________________________

Fatherrsquos Full Name _______________________________________________________________

Date of birth ______________________ _______________________ ____________________ (Day) (Month) (Year)

Degrees completed ________________________________School University __________________

Name of Employer ______________________________Title _____________________________

Address ____________________________ MOF (required) المالي _____________________الرقم

Business Phone _________________________ Cell Phone __________________________

Email Address _______________________________________________________________

Parents are 1048709 Living Together (with the child) 1048709 Divorced Separated (child living with ____________)

1048709 Other Specify ________________ ________________

Child Custody Information (If Applicable)Name of parent or guardian who has legal custody of the child ___________________________

Name(s) of parent(s) or guardian(s) who isare allowed to pick up the child from the ECC

_____________________________ _______________________________

Custody access restrictions (if applicable) _____________________________________________________________

2

If there is a Custody Order or any other Order in place that pertains to the custody andor access of the child a certified copy of the Order(s) is to be attached to this form

EMERGENCY CONTACT

In case of an emergency please specify the authorized people to be contacted

Full Name Relationship to the Child

Cell Phone

1

2

3

4

5

RELEASE INFORMATION

Please provide the following information about the people who are authorized to pick up your child from the ECC

Full Name Relationship to the Child

Cell Phone

1

2

3

4

5

PERSONAL DATA

Childrsquos Name in English (as in official documents)

_____________________________ _______________________________ _____________________________ (First) (Father) (Family)

3

Number of siblings at home _____________ Position of the child in the family _____________

Siblingrsquos Name Age Daycare School Attending (If Applicable)

1234

PREVIOUS CHILDCARE EXPERIENCE

Has your child been enrolled in any childcare previously If yes please specify for how long ________________________________________________________________________________________________

Please describe your childrsquos previous childcare experience (if applicable)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LANGUAGES ACTIVITIES

Language(s) spoken at home _____________________ _____________________ _____________________

Other language(s) that the child is exposed to _____________________ _____________________

Please list some activities that you do with your child (at home and outside)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How often do you read to your child ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC

Parentrsquos Name ______________________________ Parentrsquos Signature ______________________________

Date ______________________________

4

Medical Record Form 201_ 201_

Must be returned on your childrsquos first day at the ECC

CHILD INFORMATION

Name _________________________ _________________________ _________________________ (First) (Father) (Family)

Gender Male 1048709 Female 1048709 Blood Type _____________________

Date of Birth _________________________ _________________________ _________________________ (Day) (Month) (Year)

Home Phone(s) _________________________ _________________________

HEALTH HISTORY

Please check if the child has or may have had any of the following__ Abnormal bleeding bruising __ Dislocation (shoulder etc) __ Scarlet Fever__ Anemia __ Ear Problems __ Seizures__ Asthma __ Eye or Vision Problems __ Speech Problems__ Chicken Pox __ Hepatitis __ Tonsillitis__ Convulsions __ Measles __ Tuberculosis__ Diabetes __ Mumps __ Other__ Diphtheria __ Pneumonia

If any of the above is checked please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Did the child have any previous operation andor severe injury If yes please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SIGNIFICANT PROBLEMS

Does the child have any medical condition about which the ECC should be informed If yes please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is the child taking any medication If yes please list ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5

Please list any drug food beverage that the child is allergic to ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have a physical disability If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have any special medical problem requiring limitations on hisher physical activity If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IMMUNIZATIONSPlease indicate the last date of vaccination for the following

Required by the Ministry of Public Health in LebanonHepatitis BPolio Diphtheria Pertusis Tetanos Hemophilus Measles Mumps Rubella (MMR)Tuberculin test (PPD)RecommendedRota VirusPneumococcusMeningococcusHepatitis AChickenpox Varicella OptionalBCG (Tuberculosis) ndash OptionalTyphoid ndash Optional

Physicianrsquos Name _________________________ Physicianrsquos Signature __________________________Physicianrsquos Number(s) _________________________ _________________________Date ____________________

Medical Consent Form

In the event that my child __________________________________ becomes ill or sustains an injury while attending the ECC I give permission to the ECC nurse to administer First Aid I consent to a medical diagnosis and treatment as well as any medications necessary while under the care of the nurse I do understand that this form will apply to all future emergency situations and a copy of this form is as valid as the original This consent form will remain in effect throughout the academic year

Parentrsquos Name ___________________________ Parentrsquos Signature ___________________________

6

Date ___________________________

HEALTH INFORMATION

Name of Childrsquos Physician ___________________________________________

Work Phone _______________________ Cell Phone _______________________

Childrsquos Medical History

Type of Birth 1048709Normal 1048709 Premature 1048709 Specific Complications _________________________________________

Does the child have any medical condition about which the ECC should be informed________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Childrsquos Allergies Food Intolerance

Please list your childrsquos allergies andor food intolerance problems________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SLEEPING EATING AND TOILETING HABITS

When does your child go to bed ________________ When does your child wake up ________________

Does your child have any sleeping disturbances 1048709Yes 1048709 No If yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child feed himselfherself 1048709Yes 1048709 No

Do you have any specific concern regarding your childrsquos eating habits 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is your child toilet trained 1048709Yes 1048709 No 1048709 In the process

7

BEHAVIOR

Does your child show any aggressive behavior (kicking biting hitting yelling etc) 1048709Yes 1048709 No If yes please specify ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please explain what disciplinary measures you use with your child to deal with that________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child show any particular behavior which requires special attention at school (fear jealousy whining speech difficulty etc) 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child have temper tantrums 1048709Yes 1048709 No If yes please specify how often and how you deal with that ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What reward techniques (if any) do you use with your child at home to reinforce a positive behavior ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What makes your child angry sad andor anxious What makes your child happy Please give some specific details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8

GENERAL INFORMATION

Please indicate any other information you would like to share about your childfamily________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC I also agree to inform the ECC if there are any changes in the family relationship including any changes to the custodyaccess of my child

Parentrsquos Name ____________________________ Parentrsquos Signature ____________________________

Date ____________________________

9

Photography Consent Form

As part of the documentation process of childrenrsquos work the ECC teacherrsquos take photographs and videos of children in action as they participates in completing projects in the classrooms We would like to indicate below what uses of images of your child you are willing to consent toWe will only use the photographs in ways you agree to In any use of these images names and other personal information will NOT be identified at all

Images of my child may be used on ECCrsquos bulletin boards classroom displays and Life Cubby

Images of my child may be used as part of the LAU and ECCrsquos pamphlets brochures and information booklets

Images of my child may be used on the LAU and ECClsquos website and social media accounts

Please do not use any images of my child in any way

Please sign and return to the ECC

Name of the child

Parentrsquos Name

Relationship to the child

Signature Date

10

If there is a Custody Order or any other Order in place that pertains to the custody andor access of the child a certified copy of the Order(s) is to be attached to this form

EMERGENCY CONTACT

In case of an emergency please specify the authorized people to be contacted

Full Name Relationship to the Child

Cell Phone

1

2

3

4

5

RELEASE INFORMATION

Please provide the following information about the people who are authorized to pick up your child from the ECC

Full Name Relationship to the Child

Cell Phone

1

2

3

4

5

PERSONAL DATA

Childrsquos Name in English (as in official documents)

_____________________________ _______________________________ _____________________________ (First) (Father) (Family)

3

Number of siblings at home _____________ Position of the child in the family _____________

Siblingrsquos Name Age Daycare School Attending (If Applicable)

1234

PREVIOUS CHILDCARE EXPERIENCE

Has your child been enrolled in any childcare previously If yes please specify for how long ________________________________________________________________________________________________

Please describe your childrsquos previous childcare experience (if applicable)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LANGUAGES ACTIVITIES

Language(s) spoken at home _____________________ _____________________ _____________________

Other language(s) that the child is exposed to _____________________ _____________________

Please list some activities that you do with your child (at home and outside)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How often do you read to your child ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC

Parentrsquos Name ______________________________ Parentrsquos Signature ______________________________

Date ______________________________

4

Medical Record Form 201_ 201_

Must be returned on your childrsquos first day at the ECC

CHILD INFORMATION

Name _________________________ _________________________ _________________________ (First) (Father) (Family)

Gender Male 1048709 Female 1048709 Blood Type _____________________

Date of Birth _________________________ _________________________ _________________________ (Day) (Month) (Year)

Home Phone(s) _________________________ _________________________

HEALTH HISTORY

Please check if the child has or may have had any of the following__ Abnormal bleeding bruising __ Dislocation (shoulder etc) __ Scarlet Fever__ Anemia __ Ear Problems __ Seizures__ Asthma __ Eye or Vision Problems __ Speech Problems__ Chicken Pox __ Hepatitis __ Tonsillitis__ Convulsions __ Measles __ Tuberculosis__ Diabetes __ Mumps __ Other__ Diphtheria __ Pneumonia

If any of the above is checked please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Did the child have any previous operation andor severe injury If yes please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SIGNIFICANT PROBLEMS

Does the child have any medical condition about which the ECC should be informed If yes please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is the child taking any medication If yes please list ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5

Please list any drug food beverage that the child is allergic to ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have a physical disability If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have any special medical problem requiring limitations on hisher physical activity If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IMMUNIZATIONSPlease indicate the last date of vaccination for the following

Required by the Ministry of Public Health in LebanonHepatitis BPolio Diphtheria Pertusis Tetanos Hemophilus Measles Mumps Rubella (MMR)Tuberculin test (PPD)RecommendedRota VirusPneumococcusMeningococcusHepatitis AChickenpox Varicella OptionalBCG (Tuberculosis) ndash OptionalTyphoid ndash Optional

Physicianrsquos Name _________________________ Physicianrsquos Signature __________________________Physicianrsquos Number(s) _________________________ _________________________Date ____________________

Medical Consent Form

In the event that my child __________________________________ becomes ill or sustains an injury while attending the ECC I give permission to the ECC nurse to administer First Aid I consent to a medical diagnosis and treatment as well as any medications necessary while under the care of the nurse I do understand that this form will apply to all future emergency situations and a copy of this form is as valid as the original This consent form will remain in effect throughout the academic year

Parentrsquos Name ___________________________ Parentrsquos Signature ___________________________

6

Date ___________________________

HEALTH INFORMATION

Name of Childrsquos Physician ___________________________________________

Work Phone _______________________ Cell Phone _______________________

Childrsquos Medical History

Type of Birth 1048709Normal 1048709 Premature 1048709 Specific Complications _________________________________________

Does the child have any medical condition about which the ECC should be informed________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Childrsquos Allergies Food Intolerance

Please list your childrsquos allergies andor food intolerance problems________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SLEEPING EATING AND TOILETING HABITS

When does your child go to bed ________________ When does your child wake up ________________

Does your child have any sleeping disturbances 1048709Yes 1048709 No If yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child feed himselfherself 1048709Yes 1048709 No

Do you have any specific concern regarding your childrsquos eating habits 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is your child toilet trained 1048709Yes 1048709 No 1048709 In the process

7

BEHAVIOR

Does your child show any aggressive behavior (kicking biting hitting yelling etc) 1048709Yes 1048709 No If yes please specify ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please explain what disciplinary measures you use with your child to deal with that________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child show any particular behavior which requires special attention at school (fear jealousy whining speech difficulty etc) 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child have temper tantrums 1048709Yes 1048709 No If yes please specify how often and how you deal with that ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What reward techniques (if any) do you use with your child at home to reinforce a positive behavior ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What makes your child angry sad andor anxious What makes your child happy Please give some specific details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8

GENERAL INFORMATION

Please indicate any other information you would like to share about your childfamily________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC I also agree to inform the ECC if there are any changes in the family relationship including any changes to the custodyaccess of my child

Parentrsquos Name ____________________________ Parentrsquos Signature ____________________________

Date ____________________________

9

Photography Consent Form

As part of the documentation process of childrenrsquos work the ECC teacherrsquos take photographs and videos of children in action as they participates in completing projects in the classrooms We would like to indicate below what uses of images of your child you are willing to consent toWe will only use the photographs in ways you agree to In any use of these images names and other personal information will NOT be identified at all

Images of my child may be used on ECCrsquos bulletin boards classroom displays and Life Cubby

Images of my child may be used as part of the LAU and ECCrsquos pamphlets brochures and information booklets

Images of my child may be used on the LAU and ECClsquos website and social media accounts

Please do not use any images of my child in any way

Please sign and return to the ECC

Name of the child

Parentrsquos Name

Relationship to the child

Signature Date

10

Number of siblings at home _____________ Position of the child in the family _____________

Siblingrsquos Name Age Daycare School Attending (If Applicable)

1234

PREVIOUS CHILDCARE EXPERIENCE

Has your child been enrolled in any childcare previously If yes please specify for how long ________________________________________________________________________________________________

Please describe your childrsquos previous childcare experience (if applicable)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LANGUAGES ACTIVITIES

Language(s) spoken at home _____________________ _____________________ _____________________

Other language(s) that the child is exposed to _____________________ _____________________

Please list some activities that you do with your child (at home and outside)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How often do you read to your child ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC

Parentrsquos Name ______________________________ Parentrsquos Signature ______________________________

Date ______________________________

4

Medical Record Form 201_ 201_

Must be returned on your childrsquos first day at the ECC

CHILD INFORMATION

Name _________________________ _________________________ _________________________ (First) (Father) (Family)

Gender Male 1048709 Female 1048709 Blood Type _____________________

Date of Birth _________________________ _________________________ _________________________ (Day) (Month) (Year)

Home Phone(s) _________________________ _________________________

HEALTH HISTORY

Please check if the child has or may have had any of the following__ Abnormal bleeding bruising __ Dislocation (shoulder etc) __ Scarlet Fever__ Anemia __ Ear Problems __ Seizures__ Asthma __ Eye or Vision Problems __ Speech Problems__ Chicken Pox __ Hepatitis __ Tonsillitis__ Convulsions __ Measles __ Tuberculosis__ Diabetes __ Mumps __ Other__ Diphtheria __ Pneumonia

If any of the above is checked please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Did the child have any previous operation andor severe injury If yes please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SIGNIFICANT PROBLEMS

Does the child have any medical condition about which the ECC should be informed If yes please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is the child taking any medication If yes please list ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5

Please list any drug food beverage that the child is allergic to ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have a physical disability If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have any special medical problem requiring limitations on hisher physical activity If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IMMUNIZATIONSPlease indicate the last date of vaccination for the following

Required by the Ministry of Public Health in LebanonHepatitis BPolio Diphtheria Pertusis Tetanos Hemophilus Measles Mumps Rubella (MMR)Tuberculin test (PPD)RecommendedRota VirusPneumococcusMeningococcusHepatitis AChickenpox Varicella OptionalBCG (Tuberculosis) ndash OptionalTyphoid ndash Optional

Physicianrsquos Name _________________________ Physicianrsquos Signature __________________________Physicianrsquos Number(s) _________________________ _________________________Date ____________________

Medical Consent Form

In the event that my child __________________________________ becomes ill or sustains an injury while attending the ECC I give permission to the ECC nurse to administer First Aid I consent to a medical diagnosis and treatment as well as any medications necessary while under the care of the nurse I do understand that this form will apply to all future emergency situations and a copy of this form is as valid as the original This consent form will remain in effect throughout the academic year

Parentrsquos Name ___________________________ Parentrsquos Signature ___________________________

6

Date ___________________________

HEALTH INFORMATION

Name of Childrsquos Physician ___________________________________________

Work Phone _______________________ Cell Phone _______________________

Childrsquos Medical History

Type of Birth 1048709Normal 1048709 Premature 1048709 Specific Complications _________________________________________

Does the child have any medical condition about which the ECC should be informed________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Childrsquos Allergies Food Intolerance

Please list your childrsquos allergies andor food intolerance problems________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SLEEPING EATING AND TOILETING HABITS

When does your child go to bed ________________ When does your child wake up ________________

Does your child have any sleeping disturbances 1048709Yes 1048709 No If yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child feed himselfherself 1048709Yes 1048709 No

Do you have any specific concern regarding your childrsquos eating habits 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is your child toilet trained 1048709Yes 1048709 No 1048709 In the process

7

BEHAVIOR

Does your child show any aggressive behavior (kicking biting hitting yelling etc) 1048709Yes 1048709 No If yes please specify ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please explain what disciplinary measures you use with your child to deal with that________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child show any particular behavior which requires special attention at school (fear jealousy whining speech difficulty etc) 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child have temper tantrums 1048709Yes 1048709 No If yes please specify how often and how you deal with that ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What reward techniques (if any) do you use with your child at home to reinforce a positive behavior ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What makes your child angry sad andor anxious What makes your child happy Please give some specific details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8

GENERAL INFORMATION

Please indicate any other information you would like to share about your childfamily________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC I also agree to inform the ECC if there are any changes in the family relationship including any changes to the custodyaccess of my child

Parentrsquos Name ____________________________ Parentrsquos Signature ____________________________

Date ____________________________

9

Photography Consent Form

As part of the documentation process of childrenrsquos work the ECC teacherrsquos take photographs and videos of children in action as they participates in completing projects in the classrooms We would like to indicate below what uses of images of your child you are willing to consent toWe will only use the photographs in ways you agree to In any use of these images names and other personal information will NOT be identified at all

Images of my child may be used on ECCrsquos bulletin boards classroom displays and Life Cubby

Images of my child may be used as part of the LAU and ECCrsquos pamphlets brochures and information booklets

Images of my child may be used on the LAU and ECClsquos website and social media accounts

Please do not use any images of my child in any way

Please sign and return to the ECC

Name of the child

Parentrsquos Name

Relationship to the child

Signature Date

10

Medical Record Form 201_ 201_

Must be returned on your childrsquos first day at the ECC

CHILD INFORMATION

Name _________________________ _________________________ _________________________ (First) (Father) (Family)

Gender Male 1048709 Female 1048709 Blood Type _____________________

Date of Birth _________________________ _________________________ _________________________ (Day) (Month) (Year)

Home Phone(s) _________________________ _________________________

HEALTH HISTORY

Please check if the child has or may have had any of the following__ Abnormal bleeding bruising __ Dislocation (shoulder etc) __ Scarlet Fever__ Anemia __ Ear Problems __ Seizures__ Asthma __ Eye or Vision Problems __ Speech Problems__ Chicken Pox __ Hepatitis __ Tonsillitis__ Convulsions __ Measles __ Tuberculosis__ Diabetes __ Mumps __ Other__ Diphtheria __ Pneumonia

If any of the above is checked please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Did the child have any previous operation andor severe injury If yes please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SIGNIFICANT PROBLEMS

Does the child have any medical condition about which the ECC should be informed If yes please explain________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is the child taking any medication If yes please list ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5

Please list any drug food beverage that the child is allergic to ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have a physical disability If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have any special medical problem requiring limitations on hisher physical activity If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IMMUNIZATIONSPlease indicate the last date of vaccination for the following

Required by the Ministry of Public Health in LebanonHepatitis BPolio Diphtheria Pertusis Tetanos Hemophilus Measles Mumps Rubella (MMR)Tuberculin test (PPD)RecommendedRota VirusPneumococcusMeningococcusHepatitis AChickenpox Varicella OptionalBCG (Tuberculosis) ndash OptionalTyphoid ndash Optional

Physicianrsquos Name _________________________ Physicianrsquos Signature __________________________Physicianrsquos Number(s) _________________________ _________________________Date ____________________

Medical Consent Form

In the event that my child __________________________________ becomes ill or sustains an injury while attending the ECC I give permission to the ECC nurse to administer First Aid I consent to a medical diagnosis and treatment as well as any medications necessary while under the care of the nurse I do understand that this form will apply to all future emergency situations and a copy of this form is as valid as the original This consent form will remain in effect throughout the academic year

Parentrsquos Name ___________________________ Parentrsquos Signature ___________________________

6

Date ___________________________

HEALTH INFORMATION

Name of Childrsquos Physician ___________________________________________

Work Phone _______________________ Cell Phone _______________________

Childrsquos Medical History

Type of Birth 1048709Normal 1048709 Premature 1048709 Specific Complications _________________________________________

Does the child have any medical condition about which the ECC should be informed________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Childrsquos Allergies Food Intolerance

Please list your childrsquos allergies andor food intolerance problems________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SLEEPING EATING AND TOILETING HABITS

When does your child go to bed ________________ When does your child wake up ________________

Does your child have any sleeping disturbances 1048709Yes 1048709 No If yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child feed himselfherself 1048709Yes 1048709 No

Do you have any specific concern regarding your childrsquos eating habits 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is your child toilet trained 1048709Yes 1048709 No 1048709 In the process

7

BEHAVIOR

Does your child show any aggressive behavior (kicking biting hitting yelling etc) 1048709Yes 1048709 No If yes please specify ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please explain what disciplinary measures you use with your child to deal with that________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child show any particular behavior which requires special attention at school (fear jealousy whining speech difficulty etc) 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child have temper tantrums 1048709Yes 1048709 No If yes please specify how often and how you deal with that ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What reward techniques (if any) do you use with your child at home to reinforce a positive behavior ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What makes your child angry sad andor anxious What makes your child happy Please give some specific details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8

GENERAL INFORMATION

Please indicate any other information you would like to share about your childfamily________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC I also agree to inform the ECC if there are any changes in the family relationship including any changes to the custodyaccess of my child

Parentrsquos Name ____________________________ Parentrsquos Signature ____________________________

Date ____________________________

9

Photography Consent Form

As part of the documentation process of childrenrsquos work the ECC teacherrsquos take photographs and videos of children in action as they participates in completing projects in the classrooms We would like to indicate below what uses of images of your child you are willing to consent toWe will only use the photographs in ways you agree to In any use of these images names and other personal information will NOT be identified at all

Images of my child may be used on ECCrsquos bulletin boards classroom displays and Life Cubby

Images of my child may be used as part of the LAU and ECCrsquos pamphlets brochures and information booklets

Images of my child may be used on the LAU and ECClsquos website and social media accounts

Please do not use any images of my child in any way

Please sign and return to the ECC

Name of the child

Parentrsquos Name

Relationship to the child

Signature Date

10

Please list any drug food beverage that the child is allergic to ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have a physical disability If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child have any special medical problem requiring limitations on hisher physical activity If yes please describe it in details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IMMUNIZATIONSPlease indicate the last date of vaccination for the following

Required by the Ministry of Public Health in LebanonHepatitis BPolio Diphtheria Pertusis Tetanos Hemophilus Measles Mumps Rubella (MMR)Tuberculin test (PPD)RecommendedRota VirusPneumococcusMeningococcusHepatitis AChickenpox Varicella OptionalBCG (Tuberculosis) ndash OptionalTyphoid ndash Optional

Physicianrsquos Name _________________________ Physicianrsquos Signature __________________________Physicianrsquos Number(s) _________________________ _________________________Date ____________________

Medical Consent Form

In the event that my child __________________________________ becomes ill or sustains an injury while attending the ECC I give permission to the ECC nurse to administer First Aid I consent to a medical diagnosis and treatment as well as any medications necessary while under the care of the nurse I do understand that this form will apply to all future emergency situations and a copy of this form is as valid as the original This consent form will remain in effect throughout the academic year

Parentrsquos Name ___________________________ Parentrsquos Signature ___________________________

6

Date ___________________________

HEALTH INFORMATION

Name of Childrsquos Physician ___________________________________________

Work Phone _______________________ Cell Phone _______________________

Childrsquos Medical History

Type of Birth 1048709Normal 1048709 Premature 1048709 Specific Complications _________________________________________

Does the child have any medical condition about which the ECC should be informed________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Childrsquos Allergies Food Intolerance

Please list your childrsquos allergies andor food intolerance problems________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SLEEPING EATING AND TOILETING HABITS

When does your child go to bed ________________ When does your child wake up ________________

Does your child have any sleeping disturbances 1048709Yes 1048709 No If yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child feed himselfherself 1048709Yes 1048709 No

Do you have any specific concern regarding your childrsquos eating habits 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is your child toilet trained 1048709Yes 1048709 No 1048709 In the process

7

BEHAVIOR

Does your child show any aggressive behavior (kicking biting hitting yelling etc) 1048709Yes 1048709 No If yes please specify ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please explain what disciplinary measures you use with your child to deal with that________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child show any particular behavior which requires special attention at school (fear jealousy whining speech difficulty etc) 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child have temper tantrums 1048709Yes 1048709 No If yes please specify how often and how you deal with that ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What reward techniques (if any) do you use with your child at home to reinforce a positive behavior ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What makes your child angry sad andor anxious What makes your child happy Please give some specific details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8

GENERAL INFORMATION

Please indicate any other information you would like to share about your childfamily________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC I also agree to inform the ECC if there are any changes in the family relationship including any changes to the custodyaccess of my child

Parentrsquos Name ____________________________ Parentrsquos Signature ____________________________

Date ____________________________

9

Photography Consent Form

As part of the documentation process of childrenrsquos work the ECC teacherrsquos take photographs and videos of children in action as they participates in completing projects in the classrooms We would like to indicate below what uses of images of your child you are willing to consent toWe will only use the photographs in ways you agree to In any use of these images names and other personal information will NOT be identified at all

Images of my child may be used on ECCrsquos bulletin boards classroom displays and Life Cubby

Images of my child may be used as part of the LAU and ECCrsquos pamphlets brochures and information booklets

Images of my child may be used on the LAU and ECClsquos website and social media accounts

Please do not use any images of my child in any way

Please sign and return to the ECC

Name of the child

Parentrsquos Name

Relationship to the child

Signature Date

10

Date ___________________________

HEALTH INFORMATION

Name of Childrsquos Physician ___________________________________________

Work Phone _______________________ Cell Phone _______________________

Childrsquos Medical History

Type of Birth 1048709Normal 1048709 Premature 1048709 Specific Complications _________________________________________

Does the child have any medical condition about which the ECC should be informed________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Childrsquos Allergies Food Intolerance

Please list your childrsquos allergies andor food intolerance problems________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SLEEPING EATING AND TOILETING HABITS

When does your child go to bed ________________ When does your child wake up ________________

Does your child have any sleeping disturbances 1048709Yes 1048709 No If yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child feed himselfherself 1048709Yes 1048709 No

Do you have any specific concern regarding your childrsquos eating habits 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is your child toilet trained 1048709Yes 1048709 No 1048709 In the process

7

BEHAVIOR

Does your child show any aggressive behavior (kicking biting hitting yelling etc) 1048709Yes 1048709 No If yes please specify ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please explain what disciplinary measures you use with your child to deal with that________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child show any particular behavior which requires special attention at school (fear jealousy whining speech difficulty etc) 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child have temper tantrums 1048709Yes 1048709 No If yes please specify how often and how you deal with that ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What reward techniques (if any) do you use with your child at home to reinforce a positive behavior ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What makes your child angry sad andor anxious What makes your child happy Please give some specific details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8

GENERAL INFORMATION

Please indicate any other information you would like to share about your childfamily________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC I also agree to inform the ECC if there are any changes in the family relationship including any changes to the custodyaccess of my child

Parentrsquos Name ____________________________ Parentrsquos Signature ____________________________

Date ____________________________

9

Photography Consent Form

As part of the documentation process of childrenrsquos work the ECC teacherrsquos take photographs and videos of children in action as they participates in completing projects in the classrooms We would like to indicate below what uses of images of your child you are willing to consent toWe will only use the photographs in ways you agree to In any use of these images names and other personal information will NOT be identified at all

Images of my child may be used on ECCrsquos bulletin boards classroom displays and Life Cubby

Images of my child may be used as part of the LAU and ECCrsquos pamphlets brochures and information booklets

Images of my child may be used on the LAU and ECClsquos website and social media accounts

Please do not use any images of my child in any way

Please sign and return to the ECC

Name of the child

Parentrsquos Name

Relationship to the child

Signature Date

10

BEHAVIOR

Does your child show any aggressive behavior (kicking biting hitting yelling etc) 1048709Yes 1048709 No If yes please specify ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please explain what disciplinary measures you use with your child to deal with that________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child show any particular behavior which requires special attention at school (fear jealousy whining speech difficulty etc) 1048709Yes 1048709 NoIf yes please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your child have temper tantrums 1048709Yes 1048709 No If yes please specify how often and how you deal with that ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What reward techniques (if any) do you use with your child at home to reinforce a positive behavior ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What makes your child angry sad andor anxious What makes your child happy Please give some specific details________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8

GENERAL INFORMATION

Please indicate any other information you would like to share about your childfamily________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC I also agree to inform the ECC if there are any changes in the family relationship including any changes to the custodyaccess of my child

Parentrsquos Name ____________________________ Parentrsquos Signature ____________________________

Date ____________________________

9

Photography Consent Form

As part of the documentation process of childrenrsquos work the ECC teacherrsquos take photographs and videos of children in action as they participates in completing projects in the classrooms We would like to indicate below what uses of images of your child you are willing to consent toWe will only use the photographs in ways you agree to In any use of these images names and other personal information will NOT be identified at all

Images of my child may be used on ECCrsquos bulletin boards classroom displays and Life Cubby

Images of my child may be used as part of the LAU and ECCrsquos pamphlets brochures and information booklets

Images of my child may be used on the LAU and ECClsquos website and social media accounts

Please do not use any images of my child in any way

Please sign and return to the ECC

Name of the child

Parentrsquos Name

Relationship to the child

Signature Date

10

GENERAL INFORMATION

Please indicate any other information you would like to share about your childfamily________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I the undersigned hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC I also agree to inform the ECC if there are any changes in the family relationship including any changes to the custodyaccess of my child

Parentrsquos Name ____________________________ Parentrsquos Signature ____________________________

Date ____________________________

9

Photography Consent Form

As part of the documentation process of childrenrsquos work the ECC teacherrsquos take photographs and videos of children in action as they participates in completing projects in the classrooms We would like to indicate below what uses of images of your child you are willing to consent toWe will only use the photographs in ways you agree to In any use of these images names and other personal information will NOT be identified at all

Images of my child may be used on ECCrsquos bulletin boards classroom displays and Life Cubby

Images of my child may be used as part of the LAU and ECCrsquos pamphlets brochures and information booklets

Images of my child may be used on the LAU and ECClsquos website and social media accounts

Please do not use any images of my child in any way

Please sign and return to the ECC

Name of the child

Parentrsquos Name

Relationship to the child

Signature Date

10

Photography Consent Form

As part of the documentation process of childrenrsquos work the ECC teacherrsquos take photographs and videos of children in action as they participates in completing projects in the classrooms We would like to indicate below what uses of images of your child you are willing to consent toWe will only use the photographs in ways you agree to In any use of these images names and other personal information will NOT be identified at all

Images of my child may be used on ECCrsquos bulletin boards classroom displays and Life Cubby

Images of my child may be used as part of the LAU and ECCrsquos pamphlets brochures and information booklets

Images of my child may be used on the LAU and ECClsquos website and social media accounts

Please do not use any images of my child in any way

Please sign and return to the ECC

Name of the child

Parentrsquos Name

Relationship to the child

Signature Date

10