LCM ENROLL ATCH A&B 11-18 (

#855 (1/03) 6 pages

Date (District Use)__________________

ENROLLMENT FORM: PROVIDER OF LEGALLY-EXEMPT GROUP CHILD CARE

PARENT’S NAME:_________________________________________ CASE NUMBER: __________________

ADDRESS: __________________________________________________________________________________

TELEPHONE: (____)________________SOCIAL SECURITY NUMBER(optional):_______-_______-________

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PROGRAM NAME:____________________________________________________________________________

OWNER AND OPERATOR’S NAME:_______________________________ DATE of BIRTH: ____ /___ /____*

ADDRESS WHERE CARE IS GIVEN:____________________________________________________________

PROVIDER’S ADDRESS(If Different):____________________________________________________________

TELEPHONE: (____)________________ FEDERAL I. D. NUMBER(SSN):______________________________

* If provider is less than 18 years old, the Employment of Minors Form must be completed.

I. HOW MUCH IS THE PROVIDER CHARGING FOR EACH CHILD(IN THIS CASE)?

Child's Name Date of Birth Amount Charged (per hour/day/week)

I agree that the amount I am charging the parent signing this form is NOT MORE THAN the amount I am charging for other children of the same age.

WHO WILL SUPPLY MEALS AND SNACKS?

Meals and snacks may be supplied either by the parent or by the provider. Check the box that states what you have agreed to. If you want information about how your child care program can get money to help pay for meals and snacks, call the Child and Adult Care Food Program at (800) 942-3858.

The provider will supply snacks and meals.

The parent will supply snacks and meals.

Other - Explain: _________________________________________________

II. TYPE OF PROGRAM

PROVIDER: CHECK THE STATEMENT THAT DESCRIBES YOUR PROGRAM:

___1. This program is a nursery school, pre-kindergarten or day care program for children three years of age or older or a program for school-age children conducted during non-school hours, operated by a public school district that is providing elementary or secondary education or both in accordance with the compulsory education requirements of the NYS Education Law. The program is located on the same premises or campus where the elementary or secondary education is provided.

___2. This program is a nursery school that is voluntarily registered with the NYS Education Department and operated in accordance with Part 125 of its regulations. Attach a copy of your registration.

___3. This program is a summer day camp operated in accordance with Subpart 7-2 of the State Sanitary Code. Attach a copy of your permit from the NYS Department of Health to operate a summer day camp.

___4. This program is a day care center, family day care home or other child care program located on federal or tribal property and operated in compliance with applicable federal or tribal laws and regulations.

___5. This is a nursery school, pre-kindergarten or day care program for children three years of age or older or a program for school-aged children conducted during non-school hours, operated by a private school or academy which is providing elementary or secondary education or both in accordance with the compulsory education requirements of the NYS Education Law. The program is located on the same premises or campus where the elementary or secondary education is provided.

___6. This program is a nursery school or program for preschool-aged children operated by a nonprofit agency or organization or a private proprietary agency which is not voluntarily registered with NYS Education Department and which provides services to children for three or less hours per day.

___7. None of the above statements describe this program. If this is your answer, you may need to be licensed or registered. Until you are licensed or registered or can provide documentation that you are legally-exempt from licensing and registering requirements, the county department of social services cannot pay you to provide child care. For information about licensing, contact the Bureau of Early Childhood Services at 1-800-732-5207.

IF YOUR PROGRAM MEETS THE DEFINITION FOUND IN STATEMENTS 1, 2, 3, OR 4 ABOVE, YOU DO NOT NEED TO COMPLETE SECTION III: FACILITY SAFETY CHECKLIST. YOU MAY GO TO SECTION IV: PROVIDER AGREEMENT.

IF YOUR PROGRAM MEETS THE DEFINITION FOUND IN STATEMENTS 5 OR 6, THEN YOU MUST COMPLETE SECTION III: FACILITY SAFETY CHECKLIST.

III. FACILITY SAFETY CHECKLIST (Provider and parent should complete this form together)

A. THE PROVIDER MEETS THESE REQUIREMENTS BEFORE CARING FOR CHILDREN:

Yes No

The provider and all children have two separate & remote ways to leave the building in an emergency.

Rooms for children are well-heated, well-lighted and well-ventilated.

The facility is free of unsafe areas (such as swimming pools, open drainage ditches, wells, holes, wood or coal burning stoves, fireplaces, and gas space heaters). If there are unsafe areas, sturdy barriers are in place around the unsafe areas that keep children from getting to them.

If child care is provided above the first floor, there are barriers or locks on the windows so children can not fall out.

The water supply is safe. There are working toilets. There is hot and cold running water all the time.

The provider, each volunteer who is likely to have regular contact with the children and each employee are physically able to provide child care and are free of any communicable disease.

The facility is free of any dangerous or unsafe conditions that could hurt a child. This includes:

· Knives and other sharp objects are out of the reach of children.

· Small rugs, runners, and electrical cords are held in place so a child won’t trip.

· Electrical cords do not run under furniture or rugs and are out of the reach of small children.

· Extension cords are not overloaded.

· Any guns and other firearms are unloaded and stored in a locked drawer or cabinet and the key is kept in a safe place.

· Cords to window blinds and shades are out of the reach of children.

· Hot liquids are out of the reach of children.

· Small items that a child could choke on are out of the children's reach.

All matches, lighters, medicines/drugs, cleaning materials, detergents, aerosol spray cans and other poisonous or toxic materials are stored in their original containers. Care is taken so that they do not come in contact with children, where food is prepared, or otherwise be a danger to the children. All of these materials are stored safely away from the children.

Each child will receive meals and snacks according to what the parent and the provider have agreed.

Milk, formula and any food that goes bad if left out will be kept refrigerated.

If the provider cares for infants, formula, breast milk and other food items for infants will not be heated in a microwave oven.

The provider will always allow the custodial parent or caretaker to have access to his/her children in care, to the facility while the child is in care, and to any written records concerning the child.

The provider will hold evacuation drills at least once a month with the children so they will know what to do in an emergency.

The provider has a working telephone OR can get to one very quickly in an emergency. Emergency telephone numbers for the fire department, local police or sheriff's department, poison control center and ambulance service are posted near the phone and are easy to see.

Yes No

If a child in care is under 5 years old, protective caps, covers or permanently installed safety devices are used on all electrical outlets that children could reach.

Paint and plaster are in good repair so that there is no danger of children putting paint or plaster chips in their mouths or of it getting into food.

There is at least one operating smoke detector on each floor of the facility. The provider will check regularly to make sure all detectors work.

The facility has a portable first aid kit that is easy to get to in an emergency and is kept away from children in a clean container. It is stocked to treat common childhood injuries and problems. The provider will always replace things in the first aid kit as soon as possible after something has been used or is too old to be used.

The parent has given the provider signed proof from a doctor or other health care provider that: the child has received all of the immunizations they should have for the child’s age; OR that one or more of the immunizations would harm the child's health; OR the child's parent provides a statement saying that the child has not been immunized due to the parent's religious beliefs.

Stairs, railings, porches and balconies are in good repair.

B. THE PROVIDER AGREES TO THE FOLLOWING CONDITIONS:

The provider WILL NEVER use corporal punishment or let others use corporal punishment while children are in care. Corporal punishment means doing things directly to a child’s body to punish them such as: spanking; biting; shaking; slapping; twisting or squeezing; making the child do physical exercises beyond what is normal; forcing the child to stay still for long periods of time; making the child stay in positions that hurt the child or are bizarre; bathing the child in unusually hot or cold water; and forcing the child to eat or have in the child's mouth soap, foods, hot spices or foreign substances.

The provider WILL never use or be under the influence of alcohol or drugs while children are in care and will make sure that children do not have contact with people using drugs or alcohol while in care.

The provider WILL NOT smoke or allow smoking in indoor areas or cars or other vehicles when in use by children.

The provider, volunteers, and employees WILL NEVER leave children alone or in the care of other people.

BY SIGNING THE FACILITY SAFETY CHECKLIST, THE PARENT AND PROVIDER AGREE THAT THEY HAVE INSPECTED THE FACILITY AND THAT ALL STATEMENTS ON THE FORM ARE TRUE AND ACCURATE.

Provider Name (Print) ___________________________ Provider Signature/Date___________________________

Parent Name (Print) _____________________________ Parent Signature/Date_____________________________

IV. CRIMINAL HISTORY CERTIFICATIONS: TO BE COMPLETED BY PROVIDER

I certify to the best of my knowledge and belief that I (Choose one):

have been convicted of a crime in New York State or any other place.

have not been convicted of a crime in New York State or any other place.

I certify to the best of my knowledge and belief that any VOLUNTEER who is likely to have regular contact with children in care and any EMPLOYEE (Choose one):

has been convicted of a crime in New York State or any other place.

has not been convicted of a crime in New York State or any other place.

I certify that I have asked each volunteer who is likely to have regular contact with children in care and each employee if he or she has been convicted of a crime.

If I, or any other person listed below has been convicted of a crime, I or that other person will provide true and accurate information in writing to the parent(s) of the children I will be caring for and to the Department of Social Services concerning the crime(s), the date(s) of such convictions and any other relevant information.

I understand that I am not eligible to provide child care if I, or any other person listed below, has been convicted of a felony or misdemeanor against children.

I understand that I am not eligible to provide child care if I, or any such other person listed below, has been convicted of a violent or other serious crime unless extenuating circumstances relating to the conviction(s) exist.

I understand that I may request that the Department of Social Services review any extenuating circumstances to determine if an exception could be made to allow me to provide child care. If I request an exception, I will provide all documents or references required by the Department of Social Services.

List all volunteers who are likely to have regular contact with children in care and all employees.

_______________________________________________________________________________________

BY SIGNING THIS FORM THE PROVIDER AGREES THAT ALL STATEMENTS ARE TRUE AND ACCURATE.

Provider Name (Print) _________________________ Provider Signature/Date _____________________________

V. PARENT AND PROVIDER CERTIFICATIONS

A. PROVIDER CERTIFICATIONS:

I will notify the Department of Social Services immediately if the hours of care or number of children in my care changes.

I agree to collect the family share (fee) if instructed to do so by the Department of Social Services. I will immediately notify the Department of Social Services if the parent fails to pay the required family share. I agree to provide accurate attendance records as required by the Department of Social Services.

B. PARENT CERTIFICATIONS:

I understand that the Department of Social Services may not be able to pay a provider when the provider or any volunteer who is likely to have regular contact with my children or employee has been convicted of a crime. If the Department of Social Services determines that payment can be made to the provider when there is a criminal conviction, I have the right and responsibility to decide whether I want to use this provider. I understand that I have the right to select another provider.

I will notify the Department of Social Services if the hours that I need care or other circumstances related to my need or eligibility for care change. I agree to pay my family share (fee) as directed by the Department of Social Services.

I certify that I have selected this provider to care for my child(ren). I understand that it is my responsibility to monitor the quality of care furnished to my child(ren).

C. PARENT AND PROVIDER CERTIFICATIONS:

We state that to the best of our knowledge and belief all statements made on this form and any attachments are accurate and true. We understand that providing false or inaccurate information may result in the termination of payments and legal action by the Department of Social Services.

We state that the parent has specifically asked the provider if the provider, volunteers who are likely to have regular contact with children in care or employees have been the subject of an indicated report of child abuse or maltreatment. The provider has asked all volunteers who are likely to have regular contact with children in care and all employees if they have been the subject of an indicated report of child abuse or maltreatment. The provider has given the parent true and accurate information in writing regarding any indications of child abuse or maltreatment. The parent has considered the information given on child abuse and maltreatment indications and is choosing this provider. The parent understands he/she has the right to select another provider.

If the provider is required to complete the Facility Safety Checklist, we state that we have completed it together. We understand that payment cannot be made until items marked "No" on the Facility Safety Checklist have been corrected. We agree to notify and provide documentation to the Department of Social Services when any item on the Checklist has been corrected or changed.

By signing this form, the parent and provider agree to all of the requirements listed above.

Parent Signature/Date__________________________ Provider Signature/Date _____________________________