CHILD CARE ENROLLMENT...

CHILD CARE ENROLLMENT CHECKLIST

� Enrollment Application

� Acknowledgements

� Transportation Authorization

� Vehicle Emergency Medical Information

� General Record & Statement of Child’s Health For Admission to Child Care Facility

� Group Care Accommodations Checklist

� Grow Healthy Level B Child Care Discipline Policy

� Grow Healthy Level B Child Care Nutrition Policy

� Grow Healthy Level B Child Care Physical Activity Policy

� CACFP Paperwork

Center Specific Information

� Ages & Stages Questionnaire Letter

04/11/17

ENROLLMENT APPLICATIONSTUDENT INFORMATIONEnrollment Date Gender Male Female Date of Birth Social Security Number

Preferred Name First Name Middle Name Last Name

Name of person child lives with Relationship

PARENT/GUARDIAN INFORMATIONMother/Guardian Name Date of Birth Social Security Number

Driver’s License Number State Marital Status Married Single Divorced Separated Widowed

Home Address City, State Zip

Employer Work Address

Home Number Work Number Cell Number Email Address

Father/Guardian Name Date of Birth Social Security Number

Driver’s License Number State Marital Status Married Single Divorced Separated Widowed

Home Address City, State Zip

Employer Work Address

Home Number Work Number Cell Number Email Address

AUTHORIZED RELEASE & EMERGENCY CONTACT INFORMATIONYour child will only be released to the mother, father or guardians listed above in addition to the authorized persons listed below. Legal authorities will be contacted if your child is left at the school one hour after the school closing time. Please indicate if the persons listed below should also be used as an emergency contact.

Relation Name Home Number Work Number Emergency Contact Address

Yes No

Yes No

Yes No

Yes No

Person(s) Not Authorized to Pick Child Up*

*Appropriate documentation such as custody papers should be attached if a parent or person is not allowed to pick up the child. 04/11/17

Enrollment Date Gender Male Female Date of Birth

Child’s Preferred Name First Name Middle Name Last Name

ATTENDANCE PLANSThe weekly schedule below is intended to represent a typical week and will only be used to assist with teacher scheduling. We realize actual schedules will vary based on your needs.

Days of Attendance Normal Times of Arrival/Departure Meals Required Monday Arrival Time Breakfast Lunch Snack

Departure Time

Tuesday Arrival Time Breakfast Lunch SnackDeparture Time

Wednesday Arrival Time Breakfast Lunch SnackDeparture Time

Thursday Arrival Time Breakfast Lunch SnackDeparture Time

Friday Arrival Time Breakfast Lunch SnackDeparture Time

MEDICAL INFORMATIONChild’s Pediatrician Address Phone Number

Child’s Dentist Address Phone Number

Child Has Insurance Coverage Yes No Company Name Hospital Preference

My Child has: If you answer yes, please explain: Yes No An allergy to medicine, food, plant, animal or insect

toxin

Yes No A condition or fear that may require special care, procedures, services, medication or diet

My child had no known allergies or conditions.

PREVIOUS CHILDCARE FACILITIES ATTENDEDLocation Name Dates of Enrollment

Location Name Dates of Enrollment

Location Name Dates of Enrollment

OTHER INFORMATIONHow did you hear about us? Parent Referral Name

SIGNATURESSignature of Parent/Guardian Date

Signature of Director Date

DIRECTOR USE ONLYWithdrawal Date Withdrawal Reason

ACKNOWLEDGEMENT OF POLICIES AND PROCEDURES

InitialPlease read and initial that you have read, understand and agree to the following Big Blue Marble Academy Policies and Authorizations. Additional policies and further descriptions may be outlined in the Big Blue Marble Academy Parent Handbook and may be modified at any time or as otherwise notified by management.

Health Related Policies and AuthorizationsFever Policy If your child has a temperature of 100 degrees or more, or any symptom of a contagious disease or infection, you must make other child care arrangements. In most cases, we ask tthat your child remain at home at least 24 hours after leaving the school because of an illness. Re-admittance is at the discretion of the Director. In addition, I agree to notify Big Blue Marble Academy within 24 hours if any member of my immediate household is diagnosed with a communicable disease.

Medical Authorization I agree that Big Blue Marble Academy staff may authorize the physician of their choice to provide emergency treatment in the event that neither I nor our family physician can be contacted immediately. In the event of such accident or illness, all medical expenses incurred are my responsibility. I release Big Blue Marble Academy, and all of its owners, employees, officers, directors, servants, and agents from liability incurred as a result of any act they may perform on behalf of my child.

Medication Authorization Prescription medication will only be administered to children with written parent permission and only if required by a doctor to be given during the time of care at Big Blue Marble Academy. All paperwork must be filled out completely. Only management team members are to distribute medication and will do so according to the center medication administration schedule. We give medication only under strict guidelines as dictated by our regulatory agencies. Prescription medications will only be given to the child whose name is typed on the original prescription label. Expired medication will not be given to a child under any circumstance. Please talk to the Center Director for specific details on the Medication Administration Policy.

Pick Up Policies and ProceduresDelivery of Students I agree that when delivering my child to the school, I or the person I have authorized to drop off my child, will personally deliver my child to his/her teacher or the staff person in charge. I further agree that when picking up my child, I or the person I have designated, will personally come into the school and receive my child from his/her teacher or the staff person in charge. At no time will I leave my child at the school without first making his/her presence known to the staff, nor will I take my child from the school without notifying my child’s teacher. I further agree that I or the person I have authroized to deliver and/or pick up my child will sign my child in/out on a daily basis.

Pick Up Procedures and ID Verification We ask that parents list all possible individuals for pick up on the enrollment paperwork. If you have a need for anyone in addition to whom you have listed, you may call and give verbal consent. Please be aware that anyone picking a child up for the first time will be required to show identification. Parents are also asked to assign a code-word for additional security. Children should be clocked in and out of the online system in the lobby. Please be sure to share your code with other individuals dropping off and picking children up. (i.e. grandparents, aunts, uncles, and friends) There is a visitors log located next to the clock system. Visitors into the center will be asked to sign in upon entry into the building.

Parent Drop Off and Pick Up Policy To ensure the safety of children enrolled in our school during pick up and drop off times, please use the following policy: Upon enrolling, parent/guardians are given security codes to open the front door and a code to electronically sign their child in and out. The keypad is located in the office.

Drop Off: During drop off, parent/guardian must take their child to their assigned classroom. No child should be left unattended in the front area, left unattended to walk to his or her class room alone, or dropped off at the front door. A parent/guardian should always escort their child to their classroom. Upon entering the classroom, the parent/guardian must sign the classroom attendance sheet with the time the child is being dropped off and the signature of the person dropping the child off.

Pick Up: During pick up, parent/guardian will sign their child out of the classroom on the attendance sheet with the time they are leaving the classroom and with the signature of the authorized person picking them up. No children are allowed to exit the building without a parent/guardian. Our parking lot is really busy during drop off and pick up times, so please make sure children are supervised at all times.

Authorized Person(s) for pick up: On the enrollment application, parent/guardian has authorized person(s) to pick up their child(ren). Any person authorized to pick up your child(ren) must follow the above stated policies. It is the parent/guardian’s responsibility to share this policy with those authorized to pick up the child. All authorized people who are unknown to the staff, must have a photo id in order to pick up. No exceptions will be made.

Authorized Pick-Up Denied In the event that an authorized person comes to the center to pick up a child and a member of management feels that the individual is not in a condition to do so, we reserve the right to deny the person to transport the child. In the event that his should happen, we will: 1) If authorized person is not parent/guardian, call them first. 2) Ask if there is someone else that could be called to come get the child. 3) If person becomes aggressive or threatening, call 911.

Special PermissionsPublic/Private School Transportation I do do not give my permission for my child to be transported to and/or from a public/private school. I understand that it is the policy of Big Blue Marble Academy not to allow any child to enter or leave the school unless escorted by an adult.

School Name: Grade:

Field Trips and Special Activities I do do not give my permission for my child to participate in field trips and special activities away from the school. I understand that I will be notified in advance of any instances in which my child will be taken from the school, including the date, destination, and method of transportation of such trip. In addition, I understand that I will be required to provide written authorization for each field trip/activity away from the school.

Activities Planned Outside the Fenced Area of the Facility I do do not give my permission for my child to participate in activities planned outside the school’s fenced area.

Swimming/Water Related Activities I do do not give my permission for my child to participate in swimming/water related activities.

Media Authorization I do do not give my permission for me, my spouse, and/or my child to be photographed or videotaped by Big Blue Marble Academy. I understand that this media may be used for current/future marketing purposes on printed materials, website, and/or social media outlets.

Discipline PolicyDiscipline Policy I have received a copy of Big Blue Marble Academy’s discipline policy. The policy has been discussed with me and all my questions have been answered. I understand that Big Blue Marble Academy does not allow corporal punishment and I will be consulted for advice and/or suggestions of other possible disciplinary actions for my child if necessary.

Suspension and/or Termination Big Blue Marble Academy reserves the right to suspend or terminate a child based on behavior. Parents will be given a written one-week notification of termination, however immediate termination could occur if Big Blue Marble Academy staff feel it cannot maintain the safety and well-being of the child, other children or BBMA staff.

Safety Related Policies and ProceduresAppropriate Dress Your child will participate in both indoor play and outdoor play. Therefore, play clothes and shoes which can get dirty and allow for free and safe movement are most appropriate. For safety reasons, children cannot wear open-toe shoes, sandals or flip-flops. We also prohibit any jewelry on children, including, but not limited to, teething necklaces or bracelets. Child Abuse/Neglect As a child care provider, Big Blue Marble Academy is mandated by state law to report any cases where there is reasonable cause to believe that a child has been neglected, exploited, deprived, sexually assaulted, sexually exploited, physically injured or suffered death by other than an accidental means by a parent, guardian or caretaker, to the proper authorities. Big Blue Marble Academy will cooperate fully with the authorities in the investigation of all such cases. In accordance with state laws, children may be interviewed by investigating agencies without parental or center permission. To avoid any misunderstandings, parents are encouraged to keep the school director aware of any unusual bruises, marks or injuries occurring at home.

Center Transition and Tracking Policy Big Blue Marble Academy uses a tracking system in order to maintain ratios and supervision throughout the day. Each classroom has Transition Sheets that are created at opening each morning. Teachers are to document the time each child is dropped off and the name of the individual dropping the child off. Teachers then do a face to name count of each child in their classroom at least every 30 minutes. Teachers continue to document child attendance throughout the day. As children are moved from one class to another, children are added and deleted from transitions sheets so that there is an accurate count of children’s movement throughout the day. At the departure the teacher then documents the time the child leaves and the name of the individual picking the child up.

Emergency Medical Plan/Evacuation Plan Big Blue Marble Academy has adapted an emergency medical plan and evacuation plan that is specific to each individual center. These plans specify the route in which children are evacuated, the place in which children are transported in the event of evacuation from the premises, and the duties of each staff member in the event of an emergency. These plans are updated no less than annually and are reviewed at staff meetings. If a parent would like to review either of these plans they shall be made available. They are both kept in Emergency binders in the office.

Free and Full Access The center shall permit the parent of a child in care free and full access to his or her child without prior notice, while their child is receiving care, unless there is a court order limiting parental access. The center must be provided a copy of the court order upon enrollment or as soon as the court order has been signed, whichever occurs first.

Operational PoliciesConfidentiality Statement Information pertaining to your child is considered confidential and will not be released by Big Blue Marble Academy to third parties without first obtaining your written permission. However, it may be necessary to share relevant information relating to your child’s family situation, medical status and behavioral characteristics with authorized members of the state child care licensing agency or with persons authorized by the state licensing regulations or law to receive such information. Big Blue Marble Academy is required to comply with subpoenas for information and documentation, without parental consent.

Liability Notice Big Blue Marble Academy has liability insurance coverage. Parents will be provided a copy of the policy at request.

Provisional Employment Including Teachers From time to time circumstances may arise in which the center must provisionally employ staff members in order to meet state licensing requirements. The only events in which provisional employees will be employed are due to unexpected or emergency staff vacancies. Big Blue Marble Academy will follow all requirements set forth by the Department of Social Services before employing anyone provisionally. Occasionally to meet proper ratios and to ensure child safety, with approval from the state Licensing department, we may hire a provisional teacher. Until all paperwork has been approved the provisional employee will remain in direct supervision of a regular teacher.

07/25/17

Contact Information Change of Status I agree to notify Big Blue Marble Academy immediately of any changes that occur in the information provided in this enrollment application including work and home address, phone numbers, physician’s name, living arrangements, health information, emergency contacts, etc.

SIGNATURESChild Name Signature of Parent/Guardian Date

Child Name Signature of Director Date

TRANSPORTATION AUTHORIZATION

Child’s Name Date of Birth

Pickup Location Delivery LocationLocation Location

Time Time

Approximate Miles from pick up location to Big Blue Marble Academy Facility

Authorized Days of the Week for Transportation Monday Tuesday Wednesday Thursday Friday

Authorized Person to Receive My ChildName Phone Number

In the event the authorized person is not present to receive my child, the following procedures are to be followed:

AgreementIn the event that my child is not to be transported as outlined above, I agree to notify Big Blue Marble Academy.

Parent/Guardian Signature Date

04/11/17

VEHICLE EMERGENCY MEDICAL INFORMATION


Father’s Information Mother’s InformationFather’s Name Mother’s Name

Home Number Work Number Home Number Work Number

Emergency contact in the event parents cannot be reachedName Phone Number

Child’s Doctor Phone Number

Medical Facility the Center Uses Address

Child’s Allergies Current Prescribed Medicine

Child’s Special Needs and conditions

In the event of an emergency involving my child, and if Big Blue Marble Academy cannot get in touch with me, I hereby authorize any needed emergency medical care. I further agree to be fully responsible for all medical expenses incurred during the treat-ment of my child.


Witness Signature Date

04/11/17

South Carolina Department of Social ServicesChild Care Regulatory Services

GENERAL RECORD AND STATEMENT OF CHILD’S HEALTH FOR ADMISSIONTO CHILD CARE FACILITY

This form is to be completed for each child at the time of enrollment in the child care facility, updated as neededwhen changes occur, and maintained on file at the facility.

GENERAL INFORMATION: (to be completed by Parent or Guardian)

Name of Facility: County:

Address:

Child’s Name:

Date of Birth: Enrollment Date:

Child’s Current Home Address:

Parent/Guardian’s Full Name:

Home Phone: Work Phone: Other Phone:

Parent/Guardian’s Full Name:

Home Phone: Work Phone: Other Phone:

You must have two individuals who have the authority to obtain emergency medical treatment for the child.

1. Person responsible if parent/guardian unavailable for emergency medical services:

Address:

Telephone Number(s): Family Code Word(s):

2. Person responsible if parent/guardian unavailable for emergency medical services:

Address:

Telephone Number(s): Family Code Word(s):

Is Child currently enrolled in school? (5K up to 6 years old) Yes No

My Child will regularly attend this facility FROM am/pm TO am/pm

If Child is a drop-in, indicate hours of care: FROM am/pm TO am/pm

Check all days Child will regularly attend this facility: Mon Tue Wed Thurs Fri Sat Sun

Check all meals Child will receive daily: Meals are not offered Breakfast Morning Snack LunchAfternoon Snack Dinner Evening Snack

HEALTH INFORMATION: (to be completed by Parent or Guardian)

Family Physician or Health Resource:

Emergency Care Provider:

DSS Form 2900 (MAR 10) Edition of OCT 07 is obsolete.

Street Address – no Post Office Boxes

Last First Middle Initial Nick Name

City, State, Zip

Street Address City, State, Zip


Full Name Relationship


Full Name Relationship

Name

Street Address City, State, Zip Telephone

Emergency Facility Name


Dental Care Provider:

Health Insurance Provider:

Certificate of Immunization: Yes No N/A Please explain:

My child has the following health conditions such as allergies, asthma, diabetes, epilepsy, etc., and/or takes thefollowing medications on a regular basis:

Additional Comments:

I certify that to the best of my knowledge

is in good mental and physical health and able to participate in the child care program at

Signature: Date:

Signature: Date:

DSS Form 2900 (MAR 10) PAGE 2

Child’s Name

Name of Child Care Facility

Parent or Guardian

Director/Operator/Staff Designee

Name


GROUP CARE ACCOMMODATIONS CHECKLIST


Gender Male Female

Weight Height

Note: This Group Care Accommodations Checklist is used as part of our enrollment process to gather information to assist in meeting the needs of the children we serve. Please complete this form and return it with supporting enrollment documentation. Some information provided may require supporting documentation to make sure your child’s needs can be met. This process may take up to 5 days once all the needed informa-tion has been collected in order to make an informed enrollment decision.

Information to be completed by the parentDoes your child have a history of the following:

Asthma or other respiratory issues

Allergies, please list __________________________________

Diabetes

Seizures, list type: ____________________________________

Other medical issues, list: ______________________________

Speech therapy

Occupational therapy

Physical therapyDoes your child have an Individual Education Plan (IEP)? Yes No (If so, attach)

Does your child have an Individual Family Service Plan (IFSP)? Yes No (If so, attach)

Does your child utilize any type of specialized equipment? Yes No (If yes, explain)

Does your child have any special dietary needs? Yes No (If yes, explain)

Does your child have any developmental issues that have been identified by a physician or supporting agency?

Yes No (If yes, explain)

Does your child take any types of medication on a regular basis? Yes No (If yes, list)

Will this medication be administered at the center? Yes NoDoes the staff require any type of special training to administer the medication? Yes NoDoes the child require any specific accommodations in group care?

Sleeping: ________________________________________________

Toileting: ________________________________________________

Feeding: _________________________________________________

Medical Procedures: _____________________________________

Special Equipment: _______________________________________Will staff need special training to provide care for this child? Yes No (If yes, explain)

Parent/Guardian InformationName Home Number Alternate Number


INFORMATION RELATED TO THIS MATTER WILL BE MAINTAINED IN STRICT CONFIDENCE AND SHARED WITH PERSONNEL OF THE BIG BLUE MARBLE ACADEMY ONLY AS REQUIRED TO ASSURE THAT THE CHILD’S HEALTH CARE NEEDS ARE MET.

06/07/17

07/25/17

Policy Statement Good nutrition is vital to children’s overall development and well-being. In an effort to provide the best possible nutrition environment for the children in our facility, Big Blue Marble Academy has developed the following child care nutrition policies to encourage the development of good eating habits that will last a lifetime.

Child Care Nutrition Big Blue Marble Academy follows the child care nutrition guidelines recommended by the USDA CACFP (Child and Adult Care Food Program) for all the foods we serve. To provide a healthy and balanced diet that includes fruits, vegetables, and whole grains and limits foods and beverages that are high in sugar, and/or fat, our nutrition policy includes the following:

Fruits and Vegetables 9 We serve fruit at least 2 times a day. 9 We offer a vegetable other than white potatoes at least once a day.

Grains 9 We serve whole grain foods at least once a day.

Beverages 9 We limit juice intake to once per day in a serving size specified for the child’s age group. When served, the juice is 100% fruit

juice. 9 We do not serve sugar sweetened beverages. 9 We serve only skim or 1% milk to children age 2 years and older.

Fats and Sugars 9 High fat meats, such as bologna, bacon, and sausage, are served no more than two times per week. 9 Fried or pre-fried vegetables, including potatoes, are served no more than once per week. 9 We limit sweet food items to no more than two times per week.

Role of Staff in Nutrition Education 9 Staff provides opportunities for children to learn about nutrition 1 time per week or more. 9 Staff acts as role models for healthy eating in front of the children.

Meal and snack times are planned so that no child will go more than four hours without being offered food. We provide a variety of nutritionally balanced, high quality foods each day so please do not send your child with outside food and drinks.

All meals that are provided for field trips will be provided by Big Blue Marble Academy. No outside foods may be brought into the center without a doctor’s note or the director’s permission.

Weekly Menus Our weekly menus are carefully planned to follow child care nutrition guidelines at every meal. Each menu is designed to provide a wide variety of nutritious foods that are different in color, shape, size and texture. All of our child care menus include foods that are culturally diverse and seasonally appropriate. We also like to introduce new and different foods and include children’s favorite recipes in our menu planning. Menus are rotated on a 6 week basis to provide the children with a balance of variety and familiarity. Menus are adapted to incorporate local and fresh in-season produce when available.

Nutrition and Punishment Staff will never use food as a reward or as a punishment.

Celebrations From birthday parties to holidays there are many opportunities for celebrations in our child care center. Please be sure to discuss the food items that you would like to bring prior to the party with the center director. For holiday celebrations, a sign-up sheet with specific foods and beverages will be placed on the classroom door.

Professional Development Annual nutrition training is required to ensure that all staff understands the important role nutrition plays in the overall well-being of children.

My signature below indicates that I have received a copy of the nutrition policy, it has been reviewed with me, and I have read and understand this policy.

Printed Name Signature Date

Please circle as appropriate: STAFF PARENT If parent, name of child

NUTRITION POLICY

07/25/17

PHYSICAL ACTIVITY POLICY

Policy Statement Big Blue Marble Academy recognizes the importance of physical activity for young children. Implementation of appropriate physical activity practices supports the health and development of children in care, as well as assisting in establishing positive lifestyle habits for the future.

Physical Activity in Child Care The purpose of this policy is to ensure that children in care are supported and encouraged to engage in active play, develop fundamental movement skills and to have limited screen time. Our center encourages all children to participate in a variety of daily physical activity opportunities that are appropriate for their age, that are fun and that offer variety. In order to promote physical activity and provide all children with numerous opportunities for physical activity throughout the day Big Blue Marble Academy will:

Daily Outdoor Play 9 Encourage a least restrictive, safe environment for infants and toddlers at all times. 9 Provide a designated safe outdoor area for infants (ages 0-12 months) for daily outdoor play. 9 Provide toddlers (ages 1 through 2 year olds) with at least 60-90 minutes of daily outdoor active play opportunities across 2

or 3 separate occasions. 9 Provide preschoolers and school age children (ages 3 through 12 year olds) with at least 90-120 minutes of daily outdoor active

play opportunities across 2 or 3 separate occasions. 9 Increase indoor active play time so the total amount of active play time remains the same, if weather limits outdoor time. 9 Provide a variety of play materials (both indoors and outdoors) that promote physical activity.

Role of Staff in Physical ActivityWill encourage children to be physically active indoors and outdoors at appropriate times. Will provide 5-10 minutes of planned physical activities at least 2 times daily for children age 3 and older.

Screen Time LimitationsNot permit screen time (e.g., television, movies, video games and computers) for infants and children two years and younger.

Physical Activity and Punishment Staff members do not withhold opportunities for physical activity (e.g., not being permitted to play with the rest of the class or being kept from play time), except when a child’s behavior is dangerous to himself or others. Staff members never use physical activity or exercise as punishment, e.g., doing push-ups or running laps. Play time or other opportunities for physical activity are never withheld to enforce the completion of learning activities or academic work. Our center uses appropriate alternate strategies as consequences for negative or undesirable behaviors.

Appropriate Dress for Physical Activity We at Big Blue Marble Academy have a Ready to Play Policy! Please bring your child ready to play and have fun each day. Your child will participate in both indoor play and outdoor play. Therefore, play clothes and shoes which can get dirty and allow for free and safe movement are most appropriate. We expect parents to provide children with appropriate clothing for safe and active outdoor play during all seasons.

For safety, children cannot wear open-toe shoes, sandals or flip-flops. In winter, provide a warm jacket, snowsuit, hat, mittens and boots. In spring and fall, provide a jacket or sweater, and boots and rain jacket on rainy days. In summer, provide light clothing, swimsuit, towel, hat and sunscreen. Please label all outer garments with your child’s name!

It is our expectation that children will go outside EVERYDAYl We will monitor the weather temperatures and heat index to ensure that appropriate time frames are adhered to and we then proceed to have indoor large muscle time if need be. If you feel your child is too sick to go outside then he/she is too sick to be at the child care center. We request that you keep him/her at home until they are well enough to go outside.

Professional Development Annual training on promotion of children’s movement and physical activity is required for all staff.

My signature below indicates that I have received a copy of the physical activity policy, it has been reviewed with me, and I have read and understand this policy.



07/25/17

Policy StatementPraise and positive reinforcement are effective methods of behavior management of children. When children receive positive, nonviolent, and understanding interactions from adults and others, they develop good self-concepts, problem solving abilities, and self-discipline. Based on this belief, Big Blue Marble Academy uses a positive approach to discipline and practices the following discipline and behavior management techniques.

WE DO 9 Communicate to children using positive statements. 9 Communicate with children on their level. 9 Talk with children in a calm quiet manner. 9 Explain unacceptable behavior to children. 9 Give attention to children for positive behavior. 9 Praise and encourage the children. 9 Reason with and set limits for the children. 9 Apply rules consistently. 9 Model appropriate behavior. 9 Set up the classroom environment to prevent problems. 9 Provide alternatives and redirect children to acceptable activity. 9 Give children opportunities to make choices and solve problems. 9 Help children talk out problems and think of solutions. 9 Listen to children and respect the children’s needs, desires and feelings. 9 Provide appropriate words to help solve conflicts. 9 Use storybooks and discussion to work through common conflicts.

WE DO NOT 9 Inflict corporal punishment in any manner upon a child. (Corporal punishment is defined as the use of physical force to the

body as a discipline measure. Physical force to the body includes, but is not limited to, spanking, hitting, shaking, biting, pinching, pushing, pulling, or slapping.) And ask that anyone on premises refrains from the same.

9 Use any strategy that hurts, shames, or belittles a child. 9 Use any strategy that threatens, intimidates, or forces a child. 9 Use food as a form of reward or punishment. Use or withhold physical activity as a punishment. 9 Shame or punish a child if a bathroom accident occurs. 9 Embarrass any child in front of others. 9 Compare children. 9 Place children in a locked and/or dark room. 9 Leave any child alone, unattended or without supervision. 9 Allow discipline of a child by other children. 9 Criticize, make fun of, or otherwise belittle a child’s parents, families, or ethnic groups.

Conferences will be scheduled with parents if particular disciplinary problems occur. If a child’s behavior consistently endangers the safety of the children around him/her, then the Director has the right, after meeting with the parents and documenting behavior problems and interventions, to terminate or suspend child care services for that particular child. Parents will be given a written one-week notification of termination, however immediate termination could occur if Big Blue Marble Academy staff feel it cannot maintain the safety and well-being of the child, other children or BBMA staff.

Note: If, at any point, there is an indication/suspicion that a child may have special needs, Big Blue Marble Academy will inform the child’s family and make contact with Baby Net for assessment and assistance.

My signature below indicates that I have received a copy of the discipline policy, it has been reviewed with me, and I have read and understand this policy.



DISCIPLINE POLICY

04/11/17

PARENT PORTAL INFORMATION

Welcome to the Big Blue Marble Family!We are glad that you are now part of the Big Blue Marble Family. Please find below your information to login to the parent portal and your sign in/sign out access ID.

Website: https://family.daycareworks.com/login.jsp

User Name: ________________________________________________

Password: _________________________________________________

Sign In/Sign Out Access ID: ________________________________

Please contact your center director with questions!

05/16/17

Date Child’s Name

PAYOR INFORMATION Last Name First Name Middle Inital

Address City/State/Zip

FINANCIAL INSTITUTION INFORMATION Name Branch

Address City/State/Zip

Routing Number Account Number

Amount Date(s) of Draft Weekly Monthly

I hereby authorize Big Blue Marble Academy to automatically deduct payments from the checking account listed above. I also authorize the above-listed finan-cial institution to honor those deductions from my account.

This authorization will remain in effect until Big Blue Marble Academy has received a written request for termination. I understand if payment is returned from my financial institution, I will be responsible for bank fees and/or late fees this may cause.

Automatic Draft Authorization Form Checklist: Payor Information completed. Financial Information completed. Voided Check is attached.

Printed Name

Authorizing Signature Date

A VOIDED CHECK MUST BE SUBMITTED WITH THIS FORM.

AUTOMATIC DRAFT AUTHORIZATION FORM

LETTER FOR NON-PRICING CHILD CARE INSTITUTIONS Participating in the Child and Adult Care Food Program

Dear Parent/Guardian: This letter is intended for parents or guardians of children enrolled in a child care center. Big Blue Marble offers healthy meals to all enrolled children as part of our participation in the U.S. Department of Agriculture’s (USDA) Child and Adult Care Food Program (CACFP). The CACFP provides reimbursements for healthy meals and snacks served to children enrolled in child care. Please help us comply with the requirements of the CACFP by completing the attached Application for Free and Reduced-Price Meals in Child Care Food Program Forms (DSS Form 16160). This form will be placed in our files and treated as confidential information. All children in our program receive their meals free of charge, but the determination of eligibility category affects the amount of Federal funding received by us. Please review the following questions and answers and the instructions for completing the attached DSS Form 16160. 1. Do I need to fill out an Application for Free and Reduced-Price Meals form for each of

my children in child care? You may complete and submit one DSS Form 16160 for all children enrolled in child care in your household only if the children in child care are enrolled in the same center. We cannot approve a form that is not complete, so be sure to read the instructions carefully and fill out all required information. Return the completed form to your center Director or Assistant Director

2. Who can get free meals without providing income information? Children in households getting Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps), Family Independence (FI), or Food Distribution Program on Indian Reservations (FDPIR) can quality for free meals. Foster children and children enrolled in Head Start are also eligible for free meals. You must provide supporting documentation of a child’s enrollment in the Head Start program.

3. May I fill out a form if someone in my household is not a U.S. citizen? Yes. You or your children do not have to be U.S. citizens to qualify for meal benefits offered at the child care center.

4. Who should I include as members of my household? You must include everyone in your household (such as grandparents, other relatives, or friends who live with you) who shares income and expenses. You must include yourself and all children who live with you. You also may include foster children who live with you.

5. How do I report income information and changes in employment status? The income you report must be the total gross income listed by source for each household member received last month. If last month’s income does not accurately reflect your circumstances, you may provide a projection of your monthly income. If no significant change has occurred, you may use last month’s income as a basis to make this projection. If your household’s income is equal to or less than the amounts indicated for your household’s size on the attached Income Chart, the center will receive a higher level of reimbursement. Once properly approved for free or reduced price benefits, whether through income or by providing a current SNAP, FI or FDPIR case number, you will remain eligible for those benefits for 12 months. You should notify us, however, if you or someone in your household

becomes unemployed and the loss of income causes your household income to be within the eligibility standards.

6. What if my income is not always the same? List the amount that you normally get. For

example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month. If you normally get overtime, include it, but not if you only get it sometimes.

7. What if I have foster children? Foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income. Households may include foster children on the DSS Form 16160, but are not required to include payments received for the foster child as income.

8. We are in the military; do we include our housing and supplemental allowances as income? If your housing is part of the Military Housing Privatization Initiative and you receive the Family Subsistence Supplemental Allowance, do not include these allowances as income. Also, in regard to deployed service members, only that portion of a deployed service member’s income made available by them or on their behalf to the household will be counted as income to the household. Combat Pay, including Deployment Extension Incentive Pay (DEIP) is also excluded and will not be counted as income to the household. All other allowances must be included in your gross income.

In the operation of child feeding programs, no person will be discriminated against because of race, color, national origin, sex, age, disability or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. If you have other questions or need help, call your center Director or 803-892-5762. Thank you for your cooperation. Julie Morin Institution Representative

SOUTH CAROLINA DEPARTMENT OF SOCIAL SERVICES

POST OFFICE BOX 1520

COLUMBIA, SOUTH CAROLINA 29202-1520

Memorandum

To: Child and Adult Care Food Program Administrators

From: Mary A. Young, Program Manager

Child and Adult Care Food Program

Date: April 11, 2017

Subject: Income Eligibility Guidelines Effective July 1, 2017 to June 30, 2018

Below are the Income Eligibility Guidelines for Free and Reduced-Priced Meals that are in effect

for July 1, 2017 to June 30, 2018.

ELIGIBILITY SCALE ELIGIBILITY SCALE

FOR FREE MEALS FOR REDUCED-PRICE MEALS

HOUSE-

HOLD

SIZE

PER

YEAR MONTHLY

TWICE

PER

MONTH

EVERY

TWO

WEEKS

WEEKLY

HOUSE-

HOLD

SIZE

PER

YEAR MONTHLY

TWICE

PER

MONTH

EVERY

TWO

WEEKS

WEEKLY

1 15,678 1,307 654 603 302 1 22,311 1,860 930 859 430

2 21,112 1,760 880 812 406 2 30,044 2,504 1,252 1,156 578

3 26,546 2,213 1,107 1,021 511 3 37,777 3,149 1,575 1,453 727

4 31,980 2,665 1,333 1,230 615 4 45,510 3,793 1,897 1,751 876

5 37,414 3,118 1,559 1,439 720 5 53,243 4,437 2,219 2,048 1,024

6 42,848 3,571 1,786 1,648 824 6 60,976 5,082 2,541 2,346 1,173

7 48,282 4,024 2,012 1,857 929 7 68,709 5,726 2,863 2,643 1,322

8 53,716 4,477 2,239 2,066 1,033 8 76,442 6,371 3,186 2,941 1,471

For each

additional

member

+5,434 +453 +227 +209 +105

For each

additional

member

+7,733 +645 +323 +298 +149

If you have any questions or need further information, please contact the CACFP staff at (803)

898-0959.

INCOME ELIGIBILITY GUIDELINES FOR FREE AND REDUCED-PRICED MEALS

Effective July 1, 2017 to June 30, 2018 (Use for eligibility determinations and for public releases)

of 4 DSS Form 16160 (Jul 16) Edition of JUN 16 is obsolete

South Carolina Department of Social Services

APPLICATION FOR FREE AND REDUCED-PRICE MEALS IN CHILD CARE FOOD PROGRAMS

Part 1. Name of Enrolled Child(ren):

Part 2. List All Household Members (Including Enrolled Child(ren))

Names of all household members (First, Middle Initial, Last)

Check if No

Income

If all children listed in Part 2 are Foster, Homeless, Migrant

or Head Start skip to Part 5 to sign this

form. Attach an approval letter from the Head Start agency for all Head Start children.

Foste

r

Hom

ele

ss

Mig

rant

Head S

tart

Part 3. Benefits: If any member of your household received SNAP (formerly Food Stamps), Family Independence (FI), or FDPIR provide the name and case number for the person who receives benefits. If no one receives these benefits, skip to part 4.

NAME:_______________________________________________ CASE NUMBER: ______________________________

Part 4. Total Household Gross Income—You must tell us how much and how often

A. Name (List only household members with

income)

B. Gross income and how often it was received

1. Earnings from work before deductions

2. Welfare, child support, alimony

3. Pensions, retirement, Social Security, SSI, VA benefits

4. All Other Income

(Example) Jane Smith $200____|Weekly_ $150__|Twice a Month $100____|Monthly__ $_______|______

$_______|_______ $_______|_______ $_______|_______ $_______|______

$_______|_______ $_______|_______ $_______|_______ $_______|______

$_______|_______ $_______|_______ $_______|_______ $_______|______

$_______|_______ $_______|_______ $_______|_______ $_______|______

$_______|_______ $_______|_______ $_______|_______ $_______|______

Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign)

An adult household member must sign this form. The adult signing the form must also list the last four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on page 3 of this form.)

I certify that all information on this form is true and that all income is reported. I understand that the center or child care home will get Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.

Sign here: _________________________________________ Print name: ________________________________________

Date: ____________________________

Address: ___________________________________________ Phone Number: _______________________

City:_______________________________________________ State: ________________ Zip Code: ________________

Last four digits of Social Security Number: _*_ _*_ _*_ - _*_ _*_ - ___ ___ ___ ___ I do not have a Social Security Number


INSTRUCTIONS FOR DSS Form 16160

Follow these instructions, if your household gets SNAP (formerly Food Stamps), Family Independence (FI) or Food Distribution on Indian (FDPIR):

Part 1: List all enrolled child(ren).

Part 2: List all household members including enrolled children.

Part 3: List the case number for any household members (including adults) receiving SNAP or FI or FDPIR benefits.

Part 4: Skip this part.

Part 5: Sign and date the form. The last four digits of a Social Security Number are not necessary.

If you are applying on behalf of a FOSTER CHILD, follow these instructions:

If all children you are applying for are foster children, or if you are only applying for benefits for the foster child:


Part 2: List all foster children. Check the box indicating that the child is a foster child.



Part 5: Sign and date the form. A Social Security Number is not necessary. If some of the children in the household are foster children.


Part 2: List all enrolled children and household members. For any people, including children, with no income, you must check the “No Income Box.” Check the box if the child is a foster child.

Part 3: If the household does not have a case number, skip this part.

Part 4: Follow these instructions to report total household income from this month or last month.

Column A – Name: List only the first and last name of each person living in your household who share income and expenses, related or not (such as grandparents, other relatives, or friends who live with you) with income. Include yourself and all children living with you. Attach another sheet of paper if you need to.

Column B – Gross Income and How Often it was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received – weekly, every other week, twice a month, or monthly.

Box 1: List the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your stub or your boss can tell you.

Box 2: List the amount each person got for the month from welfare, child support, alimony.

Box 3: List retirement, Social Security, Supplemental Security Income (SSI), Veteran’s (VA) benefits, disability benefits.

Box 4: List ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits, regular contributions from people who do not live in your household, and any other income. For ONLY the self-employed, report income after expenses in Box 1. Box 4 is for your business, farm or rental property. Do not include income from SNAP, FDPIR, WIC or Federal education benefits. If you are in the Military Housing Privatization Initiative or get combat pay, do not include this housing allowance as income.

Part 5: Adult household member must sign and date the form and list the last four digits of the Social Security Number or mark the box if s/he doesn’t have one.

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:


Part 2: List all and household members including enrolled children. For any people, including children, with no income, you must check the “No Income Box.” If you are applying for a child(ren) who is homeless, migrant, Head Start or a foster child check the appropriate box. Attach a copy of the Head Start approval letter for all Head Start children.


Part 4: Follow these instructions to report total household income from this month or last month.

Column A – Name: List only the first and last name of each person living in your household who share income and expenses, related or not (such as grandparents, other relatives, or friends who live with you) with income. Include yourself and all children living with you. Attach another sheet of paper if you need to.

Column B – Gross Income and How Often it was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received – weekly, every other week, twice a month, or monthly.

Box 1: List the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your stub or your boss can tell you.

Box 2: List the amount each person got for the month from welfare, child support, alimony.

Box 3: List retirement, Social Security, Supplemental Security Income (SSI), Veteran’s (VA) benefits, disability benefits.

Box 4: List ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits, regular contributions from people who do not live in your household, and any other income. For ONLY the self-employed, report income after expenses in Box 1. Box 4 is for your business, farm or rental property. Do not include income from SNAP, FDPIR, WIC or Federal education benefits. If you are in the Military Housing Privatization Initiative or get combat pay, do not include this housing allowance as income.

Part 5: Adult household member must sign and date the form and list the last four digits of the Social Security Number or mark the box if s/he doesn’t have one.


Part 6. Participant’s ethnic and racial identities (optional)

Mark one ethnic identity: Mark one or more racial identities:

Hispanic or Latino

Not Hispanic or Latino

Asian American Indian or Alaska Native

White Native Hawaiian or Other Pacific Islander

Black or African American

The participant in the child care facility may qualify for free or reduced price meals if your household income falls within the limits on this chart.

Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not

have to give the information, but if you do not, we cannot approve the participant for free or reduced price meals. You must include the last four digits of the Social Security Number of the adult household member who signs the application. The Social Security Number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Family Independence (FI) or Food Distribution Program on Indian Reservations (FDPIR) case number for the participant or other (FDPIR) identifier, or when you indicate that the adult household member signing the application does not have a Social Security Number. We will use your information to determine if the participant is eligible for free or reduced price meals, and for administration and enforcement of the Program.

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance with Federal

civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights,1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. This institution is an equal opportunity provider.

For Sponsoring Organization or Child Care Facility Use ONLY.

FOSTER CHILDREN: Are there foster children listed on page 1? Yes No

Foster Children are categorically eligible for free. Centers should mark these children free on the Master Roster. Sponsors of homes should mark these children Tier I.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12

Total Income: ___________________ Per: Week, Every 2 Weeks, Twice A Month, Month, Year

Household size: _________

For All Other Children: Eligibility: Free_____ Reduced_____ Paid_____ For Child Care Homes Only: Tier I_____ Tier II_____

Reason: ____________________________________________________________________________________________________

Determining Official’s Signature: ______________________________________________________________ Date: ______________

Confirming Official’s Signature: _______________________________________________________________ Date: ______________

Household size Yearly

1 $ 21,978

2 29,637

3 37,296

4 44,955

5 52,614

6 60,273

7 67,951

8 75,647

Each additional person: + 7,696

http://www.ocio.usda.gov/sites/default/files/docs/2012/Complain_combined_6_8_12.pdf

http://www.ascr.usda.gov/complaint_filing_cust.html


INSTRUCTIONS FOR COMPLETING DSS Form 16160

ALL HOUSEHOLDS:

Part 6: Answer this question if you choose.

Privacy Act Statement: This explains how we will use the information you give us.

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly.

For Sponsoring Organization or Child Care Use ONLY: To be complete by CACFP Institutions only.

Building For the Future This day care facility participates in the Child and Adult Care Food Program (CACFP), a Federal program that provides healthy meals and snacks to children receiving day care.

Each day more than 2.6 million children participate in CACFP at day care homes and centers across the country. Providers are reimbursed for serving nutritious meals which meet USDA requirements. The program plays a vital role in improving the quality of day care and making it more affordable for low-income families.

Meals CACFP homes and centers follow meal requirements established by USDA.

Breakfast Lunch or Supper Snacks (Two of the four groups: )

Milk

Fruit or Vegetable

Grains or Bread

Milk

Meat or meat alternate

Grains or bread

Two different servings of fruits

or vegetables

Milk

Meat or meat alternate

Grains or bread

Fruit or vegetable

Participating

Facilities Many different homes and centers operate CACFP and share the common goal of bringing

nutritious meals and snacks to participants. Participating facilities include:

• Child Care Centers: Licensed or approved public or private nonprofit child care centers, Head Start programs, and some for-profit centers.

• Family Day Care Homes: Licensed or approved private homes.

• Afterschool Care Programs: Centers in low-income areas provide free snacks to school-age children and youth.

• Homeless Shelters: Emergency shelters provide food services to homeless children.

Eligibility State agencies reimburse facilities that offer non-residential day care to the following children:

• children age 12 and under, • migrant children age 15 and younger, and • youths through age 18 in afterschool care programs in needy areas.

Contact Information If you have questions about CACFP, please contact one of the following:

Sponsoring Organization/Center State Agency Director,

SC Department of Social Services Child and Adult Care Food Program Post Office Box 1520 Columbia, SC 29202 803-898-0959

USDA is an equal opportunity provider and employer English Version

Construyendo Para El Futuro

Esta guardería infantil diurna participa en el Programa de Alimentación Para Niños y Adultos en Guarderías (CACFP por sus siglas en inglés: Child and Adult Care Food Program) un programa Federal que provee comidas y bocadillos saludables a niños y a adultos en guarderías diurnas. Todos los días, más de 2.6 millones de niños participan en el programa del CACFP en centros y en hogares de familia para el cuidado de niños. Los proveedores son reembolsados por servir comidas nutritivas que cumplen con los requisitos establecidos por el Departamento de Agricultura de los Estados Unidos (USDA). El programa juega un papel vital al mejorar la calidad de las guarderías y al poner las guarderías al alcance económico de familias de bajos recursos.

Alimentos Hogares y centros del CACFP siguen los patrones alimentarios establecidos por USDA.

Desayuno Almuerzo o Comida Bocadillos (Dos de los cuatro grupos)

Leche Fruta o verdura Granos o pn

Leche Carne o un alternativo de carne Granos o pan Dos porciones diferentes de frutas o verduras

Leche Carne o un alternativo de carne Granos o pan Fruta o verdura

Establecimientos Muchos tipos de establecimientos diferentes operan el CACFP, compartiendo todos el objetivo común

del CACFP de brindar comidas y bocadillos nutritivos a sus participantes. Estos incluyen:

• Centros de Cuidado de Niños (Child Care Centers) Centros para el cuidado de niños, ya sean públicos o privados pero no lucrativos, que hayan sido licenciados o aprobados; programas del Head Start, y algunos centros para por lucro.

• Hogares de Familia Para el Cuidado de Niños (Family Day Care Homes) Hogares privados licensiados o aprobados.

• Programas Escolares Después de Clases (Afterschool Care Programs) Centros en areas geográficas de bajos ingresos que proveen bocadillos gratis a niños de edad escolar y a jóvenes.

• Centros de Refugio Para Gente Sin Hogar (Homeless Shelters) Centros de emergencia de refugio que proveen servicios residenciales y de comidas a niños sin hogares.

Elegibilidad Agencias estatales reembolsan establecimientos que ofrecen cuidado no residencial a los

siguientes niños:

• niños hasta los 12 años de edad,

• niños de familias migratorias hasta los 15 años de edad,

• jóvenes hasta los 18 años de edad en programs escolares después de clases en areas de necesidad.

Para Más Si está interesado en participar el el CACFP, por favor pongase en contacto con uno de los siguientes: Información

Organización Patrocinadora/Centro State Agency Director SC Department of Social Services Child And Adult Care Food Program Post Office Box 1520 Columbia, SC 29202 803-898-0959

USDA es un proveedor y empleador que ofrece oportunidad igual a todos Spanish version

South Carolina Department of Social ServicesINFANT STATEMENT

From: Child Care Center/Provider:

Sponsoring Organization:

To: Parent/Guardian of Infant(s) in Day Care

I am required by the Child and Adult Day Care Food Program to offer a CACFP meal to all enrolled infants in my care.A CACFP meal includes iron fortified infant cereal and baby food when appropriate for the child’s age. A copy of theCACFP infant meal pattern is attached.

I am required to offer an infant formula, which meets program requirements to all enrolled infants in my care. The formulathat I am providing is iron fortified . There will be no additional charge to you, if youwould like your infant to receive the formula that I am offering.

I understand that not all infants need the same formula, and that the formula served to your infant should be the onerecommended by your physician. If you choose, you may continue to provide your infant’s formula and other food items.

Parent/Guardian, please check the following statement that applies to you. Then sign and date below:

I would like the child care provider to serve my infant the iron fortified infant formula listed above. I understand thatbesides the formula, the caregiver will offer my infant other food items, approved by the CACFP meal patternguidelines, at no additional charge to me.

I will supply the breast milk/infant formula to the child care provider to serve to my infant. The name of the formula Iwill provide is: . I understand that the caregiver will offer other food items,approved by the CACFP meal pattern guidelines, to my child.

I will provide breast milk/infant formula and all other meal items to my child care provider to serve to my infant.

Name of Infant: Birth Date:

Signature of Parent/Guardian: Date:

Signature of Provider: Date:

DSS Form 3354 (APR 04)

Reset

Big Blue Marble Academy

Big Blue Marble Acedemy

If Similac AdvanceIF Similac Advance

Departamento de Servicios Sociales de Carolina del SurDECLARACIÓN SOBRE INFANTE

De: Centro de Cuidado de Niños/ Proveedor:

Organización Patrocinadora:

Para: Padre/ Tutor de Infante(s) en Day Care (Guardería de Niños)

Yo estoy requerido por el Child and Adult Day Care Food Program (programa de comida para niños y adultos en centrosde cuidado) a ofrecerles comida de CACFP a todos los infantes en que estén inscritos en esta guardería. La comida deCACFP incluye cereal para infantes fortificado con hierro y comida para bebé cuando sean apropiadas para la edad delinfante. Se adjunta una copia de la muestra de la comida para infantes de CACFP.

Yo estoy requerido a ofrecer fórmula para infantes, que completen los requisitos del programa para inscribir infantes enmi guardería. La fórmula que estoy dando es fortificado con hierro. Si usted quiereque su infante reciba la fórmula que yo le estoy ofreciendo, no habrá costo adicional.

Yo entiendo que no todos los infantes necesitan la misma fórmula y que la fórmula servida a su infante debería ser la quesu doctor recomendó. Si usted escoge, usted puede continuar proveyendo la fórmula para su infante y otros tipos decomida.

Padre/ Tutor, por favor marque la declaración que se aplica a usted. Después fírmela y escriba la fecha en laparte inferior.

�� Me gustaría que el proveedor de cuidado infantil le sirva a mi hijo fórmula para infante fortificado con hierro listadaarriba. Yo entiendo que además de la fórmula, el cuidador le ofrecerá a mi niño otras comidas sin ningún costoadicional, aprobadas por las guías de comida de CACFP.

�� Yo le daré la leche de pecho/ fórmula al proveedor de cuidado infantil para que se la sirva a mi niño. El nombre dela fórmula que le daré es: . Yo entiendo que el cuidador de mi niño le daráotras comidas, aprobadas por las guías de comida de CACFP.

�� Yo le daré leche de pecho/ fórmula y todas las otras comidas al cuidador de niño para que se la sirva a mi niño.

Nombre de Infante: Fecha de Nacimiento:

Firma de Padre/ Tutor: Fecha:

Firma de Proveedor: Fecha:

DSS Form 3354 SPA (APR 04)

Reset



formula de infantes Similac Advance

07/25/17

USDA NONDISCRIMINATION STATEMENT

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected].

This institution is an equal opportunity provider.

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