Summer Transition Enrollment Pack

Location:(Required)

School Year:(Required)

FOR PROVIDER USE ONLY

Provider Legal Name:

School/Site Name:

CHILD'S INFORMATION

Child’s Full Name:(Required)

First Middle Last Suffix

Name Child is Called:(Required)

Social Security Number:(Required)

Date of Birth:(Required)

Child’s Gender:

Male

Female

Home Address:(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone Number:(Required)

Do you need before and after school care?(Required)

Yes

Did your child attend a Georgia's Pre-K Program this school year?(Required)

Yes

School Name:

Was your child on a waiting list for Georgia's Pre-K?(Required)

Yes

School Name:

If your child did not attend Georgia's Pre-K Program, where was your child this school year?

(home, private preschool, church preschool, daycare program, Head Start, relatives, etc.)

MOTHER'S INFORMATION

Mother’s Full Name:(Required)

First Middle Initial Last

Mother’s Home Address (if different from child):

Street Address Address Line 2 City State ZIP Code

Home Phone:(Required)

Cell Phone:(Required)

Mother’s Place of Employment:(Required)

Work Phone:(Required)

Employer’s Address:(Required)

Street Address Address Line 2 City State ZIP Code

FATHER'S INFORMATION

Father’s Full Name:(Required)

First Middle Initial Last

Father’s Home Address (if different from child):

Street Address Address Line 2 City State ZIP Code

Home Phone:(Required)

Day Time Phone:(Required)

Father’s Place of Employment:(Required)

Employer’s Address:(Required)

Street Address Address Line 2 City State ZIP Code

Work Phone:(Required)

EMERGENCY CONTACTS & AUTHORIZED PICK UP RESPONSES

1ST CONTACT / PICK UP PERSON

Name:(Required)

First Last

Relationship:(Required)

Cell Phone:(Required)

Alternate Phone:(Required)

Email:(Required)

2ND CONTACT / PICK UP PERSON

Name:

First Last

Relationship:

Cell Phone:

Alternate Phone:

Email:

Signature (Parent/Guardian):(Required)

Date:(Required)

CHILD MAINTENANCE

Child's Living Arrangements:(Required)

Both Parents

Mother

Father

Other

Child's Legal Guardian:(Required)

Both Parents

Mother

Father

Other

This child may be released to the person(s) signing this agreement or to the following:

Name

Address

Phone Number

(please use the + button to add more fields for each person)

Child's Physician or Clinic's Name (child's primary health source):(Required)

Phone:(Required)

My child has the following special need(s):(Required)

The following special accommodation(s) may be required to most effectively meet my child's needs while at this center:(Required)

My child is currently on medication(s) prescribed for long-term continous use and/or has the following pre-existing allergies, illness, or health concerns:(Required)

GENERAL RELEASE

Signature (Parent/Guardian):(Required)

Date:(Required)

PHOTOGRAPH/VIDEOTAPE RELEASE

Pre-K Provider Name/Address:(Required)

Signature (Parent/Guardian):(Required)

Date:(Required)

SUMMER TRANSITION - ROSTER INFORMATION FORM

Child's Legal Full Name (Nombre legal completo del niño):(Required)

First (Primer) Middle (Segundo) Last (Apellido) Suffix (Sufijo)

Child's Social Security Number (Número de seguro social del niño):(Required)

Date of Birth(Fecha de nacimiento):(Required)

Gender(Sexo):(Required)

Male

Female

Date enrolled in Pre-K:(Required)

If different from birth certificate, name student is called:

1. Everyone must answer the following question. (Todos deben contestar la pregunta

Is your child's ethnicity Hispanic/Latino/Spanish Origin, regardless of race? (¿Es Ud. Hispano/Latino o de Origen Hispano, sin importar la raza?)(Required)

Yes (Si)

No (No)

3. EVERYONE must select ONE OR MORE of the following races regardless of how you answered question one. (TODOS deben seleccionar UNA O MAS de las siguientes razas sin importar cómo haya contestado la primera pregunta.)

Is your child:(Required)

a. White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. (Blanco - Una persona que tiene origenes en los pueblos provenientes de Europa, el Medio Oriente, o Africa del Norte).

b. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. (Asiática - Una persona con origenes en los pueblos provenientes del Lojano Oriente, Suroeste de Asia, o el subcontinente Hindú incluyendo, a Cambodia, China, India, Japón, Corea, Malasia, Pakistán, Las Filipinas, Tailandia, y Vietnam.)

c. Native Hawallan or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. (Nativo de Hawall u Otra Isla del Pacifico Una persona con origenes en los pueblos provenientes de Hawaii, Guam, Samoa, u otra Isla del Pacifico.)

d. Black or African American - A person having origins in any of the Black racial groups of Africa. (Negro o Afro Americano - Una persona con origenes en los pueblos provenientes de! Africa o en grupo racial Negro.)

e. American Indian or Alaskan Native - A person having origins in any of the original peoples of North and South America including Central America, who maintains a tribal affiliation or community attachment. (Indio Americano o Nativo de Alaska - Una persona con origenes en los pueblos provenientes de América Del Norte y del Sur, incluyendo América Central, que mantiene una afiliación tribal o comunitaria.)

What is your child's primary language? (¿Cuál es el idioma primario de su hijo(a)?)(Required)

English (Inglés)

A language other than English (Un idioma diferente al Inglés)

4. Was your child born as a: (El parto en que Ud. tuvo a su hijo(a) fue de:)(Required)

Single Birth (1) (Un sólo niño)

Twin (2) (De mellizos)

Triplet (3) (De trillizos)

Quadruplet (4) (De cuatrillizos)

Quintuplet (5) (De quintuples)

5. Does your child have an Individualized Education Plan (IEP)? (¿Tiene su hijo(a) un Plan de Educación Individualizada (IEP?))(Required)

Yes (Si)

No (No)

6. Does your child receive any of the following services? (¿Recibe su hijo(a) alguno de estos servicios?)(Required)

Childcare and Parent Services (CAPS) (child care subsidy program)

Food Stamps (Cupones de Alimentos)

SSI

Medicaid

Temporary Assistance for Needy Families (TANF)

Not Applicable

7. Will the Pre-K center be providing transportation for your child? (Recibirá su hijo(a) transporte en el Centro donde va a asistir a Pre-K?)(Required)

Yes (Si)

No (No)

Parent/Guardian Signature:(Required)

Date:(Required)

SUMMER TRANSITION - AGREEMENT FORM

Parent/Guardian Name:(Required)

Child's Name:(Required)

Therefore, I agree to:(Required)

Send my child to school each day for all instructional days (29 total days)

Send my child to school on time each day.

Be available for regular home/school visits with the Transition Coach and/or the teachers as needed.

Participate in parent/teacher conferences as needed

Participate in family engagement activities offered each week

Provide all required documentation for enrolling in STP

Signature of Parent/Guardian:(Required)

Date:(Required)

SUMMER TRANSITION - FAMILY SURVEY

In an effort to identify and best serve the needs of the families and children in the Summer Transition Program, we ask that you complete the following survey. The survey will assist the Transition Coach in planning activities throughout the six-week program.

Parent/Guardian Name:(Required)

Email Address:(Required)

Best Contact Phone Number:(Required)

Child's Name:(Required)

Please check any topics that would be of interest to you:(Required)

If "Other", please explain:

Please check any areas of need for which you would like assistance:(Required)

Housing

Budget Counseling

Clothing

Education

Employment

After School Child Care

What is your preferred method of communication?(Required)

Phone Call

Text

Other

Email:

Phone:

If "other", please explain:

Phone:

Please list the best time for you to participate in workshops and activities:(Required)

Morning

Afternoon

Evening

Please list the times for the selected:(Required)

In order for me to participate in the parent activities, I would need assistance with the following:(Required)

Child Care

Transportation

Other

I do not need assistance with any of the above

If "other", please explain:

Are you interested in volunteering during the Summer Transition Program?(Required)

Yes

Comments or Suggestions:

PROCARE - PARENT GUIDE TO SIGN IN/OUT

Please see the following linked pages for the Parent Guide to Sign In/Out of Procare.
Click to view page 1 | Click to view page 2

HEALTH INFORMATION AND EMERGENCY PERMISSION

Child’s Full Name:(Required)

First Middle Last

Date of Birth:(Required)

Phone Number:(Required)

Street Address:(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian 1:(Required)

Phone:(Required)

Parent/Guardian 2:(Required)

Phone:(Required)

Doctor’s Name:(Required)

Phone:(Required)

Dentist’s Name:(Required)

Phone:(Required)

Health Insurance Provider:(Required)

Phone:(Required)

Insurance Member ID #:(Required)

Primary Insured’s Name & Date of Birth:(Required)

Should your child become injured or ill while in the care of A Kid’s World and you are unable to be contacted, A Kid’s World is authorized to secure medical attention as deemed necessary. By signing below the parent acknowledges that A Kid’s World does not provide medical insurance to the children in our program and the parent shall assume responsibility for any/all medical expenses. Also, by signing below you agree to hold A Kid’s World and its staff members harmless to any claims that may arise during my child’s enrollment in the program.

Parent’s Signature:(Required)

Date:(Required)

Does your child have physical problems, mental health disorders or developmental disabilities affecting participation in school activities?(Required)

Yes

Specify:

Does your child have allergies? (foods, medications, insects, etc.?)(Required)

Yes

Specify:

Are there any special procedures required in caring for your child?(Required)

Yes

Specify:

EMERGENCY CONTACTS: (if parent/guardian cannot be reached)

Name:(Required)

Relationship:(Required)

Phone 1:(Required)

Phone 2:(Required)

Name:(Required)

Relationship:(Required)

Phone 1:(Required)

Phone 2:(Required)

A Kid’s World Emergency Medical Procedures:

1. Call emergency medical team, if necessary

2. Call parent/guardian

3. Call alternate emergency contact, if necessary

4. Emergency medical team transport child to hospital, if necessary

5. A Kid’s World Representative will accompany child to the hospital

Hospital A Kid’s World Uses:
PIEDMONT WALTON
2151 West Spring Street
Monroe, GA 30655
770-267-8461

Parent/Guardian Name:(Required)

Child Name:(Required)

Parent/Guardian Signature:(Required)

Date:(Required)

TRANSPORTATION AGREEMENT

Child’s Name:(Required)

Date of Birth:(Required)

Signature (Parent/Guardian):(Required)

Date:(Required)

TRANSPORTATION AGREEMENT FOR SCHOOL AGE USE ONLY

If the child relocates to another school or the hours change, this form must be updated.

Name of School:

School Phone:

School Address:

Street Address Address Line 2 City State ZIP Code

• In the event the designated location is unable to receive children they will be returned to AKW

• It is vital that AKW be notified of any changes in the above scheduled transportation.

• AKW will assume the above schedule of transportation will be followed unless we receive different instructions from parents. Instructions should be received at AKW no later than 1hr prior to pick up time.

To Above Listed School at (am/pm):

From Above Listed School at (am/pm):

On the following days (Please Check All That Apply)

Monday

Tuesday

Wednesday

Thursday

Friday

PHOTO RELEASE FORM

Child's Name:(Required)

Date:(Required)

Parent/Guardian Name:(Required)

Parent/Guardian Signature:(Required)

SOCIAL MEDIA RELEASE

Child’s Name:(Required)

Parent’s Signature:(Required)

AUTHORIZATION TO DISPENSE EXTERNAL PREPARATIONS

Parental Authorization. Except for first aid, personnel shall not dispense personnel shall not dispense prescription or non-prescription medications to a child without specific written authorization from the child’s physician or parent. Such authorization will include, when applicable, date; full name of the child; name of the medication; prescription number, if any; dosage; the dates to be given; the time of day to be dispensed; and signature of parent.

Check All That Apply(Required)

Baby Wipes

Band-Aids

Neosporin or similar ointment

Bactine or similar first aid spray

Sunscreen

Insect Repellent

Non-prescription ointment (such as A & D, Destin, Vaseline)

Other

If Other, please specify:

Parent/Guardian Signature:(Required)

Date:(Required)

USDA FOOD PROGRAM

Dear Parents,
The USDA Food Program is a subsidized program that allows our center to provide high quality, large portioned meals to our children without any additional cost to our families.

In order for our center to qualify for this program we must prove that at least 25% of our families meet the “Free or Reduced” income standards. To do this we must maintain income verification forms on all families that attend our center. Even if you do not feel like your income would help us “qualify”, we still must maintain a verification form for your family. We must update our forms every August.

Please feel sure that this information is maintained separate from children’s records and only the management team had access to this information. This information is not used for any other purpose.

In addition, please complete all areas of this form! If your form is not filled out and signed, we have to count your family as a paid family regardless of your income!

Thank you for your help and understand. Please feel confident in knowing that our center’s participation in the USDA Food Program allows A Kid’s World to serve high quality meals to our children.

Sincerely,
Shannon Smith
Director/Owner
A Kid’s World
770-786-1587

CACFP Meal Benefit Income Eligibility Statement

PART I: Child(ren) or Adult enrolled to receive day care

1. Name:

First Middle Initial Last

SNAP, TANF, or FDPIR case number, or Client ID number for children only. All the above, or SSI or Medicaid case number for Adults. Note: Do not use EBT numbers. Write case number and proceed to Part Ill.

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeu0002less are eligible for free meals:

Head Start

Foster Child

Migrant

Runaway

Homeless

(Check All That Apply)

2. Name:

First Middle Initial Last

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeu0002less are eligible for free meals:

Head Start

Foster Child

Migrant

Runaway

Homeless

(Check All That Apply)

3. Name:

First Middle Initial Last

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeu0002less are eligible for free meals:

Head Start

Foster Child

Migrant

Runaway

Homeless

(Check All That Apply)

4. Name:

First Middle Initial Last

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeu0002less are eligible for free meals:

Head Start

Foster Child

Migrant

Runaway

Homeless

(Check All That Apply)

5. Name:

First Middle Initial Last

Children in Head Start, foster care and children who meet the definition of migrant, runaway, or homeu0002less are eligible for free meals:

Head Start

Foster Child

Migrant

Runaway

Homeless

(Check All That Apply)

PART II: Report income for ALL Household Members (Skip this step if participant is categorically eligible as documented in Part 1.) Are you unsure what income to include here? Flip the page and review the charts titled “Sources of Income” for more information.

A. Child lncome1 - Sometimes children in the household earn or receive income. Please indicate the TOTAL income received by child household members listed in PART I here

Child Income:

How Often?

B. Other Household Members1 - List all household members even if they do not receive income. Also, list the adult participant if he/she did not meet eligibility in Part I. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘O’. If you enter “O” or leave any field blank you are certifying (promising) there is no income to report

1. Name of Other Household Member:

Earnings from work before deductions:

How Often?

Welfare, child support, alimony:

How Often?

Social Security, pensions, retirement:

How Often?

All other incomes:

How Often?

2. Name of Other Household Member:

Earnings from work before deductions:

How Often?

Welfare, child support, alimony:

How Often?

Social Security, pensions, retirement:

How Often?

All other incomes:

How Often?

3. Name of Other Household Member:

Earnings from work before deductions:

How Often?

Welfare, child support, alimony:

How Often?

Social Security, pensions, retirement:

How Often?

All other incomes:

How Often?

4. Name of Other Household Member:

Earnings from work before deductions:

How Often?

Welfare, child support, alimony:

How Often?

Social Security, pensions, retirement:

How Often?

All other incomes:

How Often?

5. Name of Other Household Member:

Earnings from work before deductions:

How Often?

Welfare, child support, alimony:

How Often?

Social Security, pensions, retirement:

How Often?

All other incomes:

How Often?

C. Total Household Members (Adults and Children) listed in Part I and Part II

Total Household Members:

Social Security Number. If income is listed or completed in Part II, the adult completing the form must also list the last four digits of his or her Social Security Number or check the “I don’t have a Social Security Number” box below. (See Privacy Act Statement on next page). Failure to complete this section, if income is listed, will result in the denial of free or reduced eligibility

Last four Digits of Social Security Number XXX-XX:

PART III: Enrollment Information Children Only

My child is normally in attendance at the facility between the hours of (am/pm):

To (am/pm):

Check the days your child will normally attend the center:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Check the meals your child will normally receive while in care:

Breakfast

AM Snack

Lunch

PM Snack

Supper

Evening Snack

PART IV: Signature

*This application Is a revision of USDA’s newly released meal benefit prototype and meets all legal requirements and reflect design best practices identified by USDA through focus testing and other research

Signature: X

Print Name:

Date:

Phone:

Address:

Street Address Address Line 2 City State ZIP Code

PART V: Participant’s Ethnic and Racial Identities (optional)

Select one ethnic identity:

Hispanic/ Latino

Not Hispanic/ Latino

Check one or more racial identities:

Asian

Black or African American

Hawaiian or other Pacific Islander

White

Indian or Alaska Native

Official Use Only Section for Provider: 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 ☐ Monthly ☐ Yearly ☐ Household Size:

Categorical Eligibility: check ( ☐ ) if applicable Eligibility: check ONE ( ☐): Free ☐ Reduced ☐ Paid

Day Care Homes Only: check ( ☐) ONE ☐ Tier I ☐ Tier II

When more than one person is performing CACFP duties, there must be at least two signatures on this form: one signature from the Determining Official (the official who determined initial income classification) and one signature from the Confirming Official (the official who verified the form’s accuracy).

Determining Official’s Signature: Date

Confirming Official’s Signature: Date

Follow Up Official’s Signature: Date

WIC - A Special Food and Nutrition Education Program for Women, Infants and Children

WHO IS ELIGIBLE? » A pregnant woman » A breastfeeding woman » A woman who has recently been pregnant » An infant or a child less than 5 years old	TO BE ELIGIBLE, YOU MUST ALSO: » Have a low or moderate income AND » Have a special need that can be helped by WIC foods and nutrition counseling
APPROVED WIC FOODS: Milk, cheese, eggs, cereals, peanut butter, fruit or vegetable juices, dry beans or peas, iron fortified formula	SERVICES PROVIDED: » Nutritious foods » Nutrition counseling » Breast feeding support » Health care referral

You do not have to be on public assistance to apply. Call your local health department for more information.

GEORGIA WIC PROGRAM
Georgia Department of Public Health
2 Peachtree Street NW, 10th Floor
Atlanta, GA 30303
Telephone: 1-800-228-9173
Website: http://dph.georgia.gov/WIC

INCOME ELIGIBILITY GUIDELINES
(Effective from July 1, 2021 to June 30, 2022)

Household Size	Reduced Meal Income Limits
	Annually	Monthly	Twice A Month	Every Two Weeks	Weekly
1 …..	23,828	1,986	993	917	459
2 …..	32,277	2,686	1,343	1,240	620
3 …..	40,626	3,386	1,693	1,563	782
4 …..	49,025	4,086	2,043	1,886	943
5 …..	57,424	4,786	2,393	2,209	1,105
6 …..	65,823	5,486	2,743	2,532	1,266
7 …..	74,222	6,186	3,093	2,855	1,428
8 …..	82,621	6,886	3,443	3,178	1,589
For each additional family member add	+ 8,399	+700	+ 350	+324	+162

ALL ABOUT ME AND MY FAMILY

Dear Family,
We welcome you and your child to our classroom community! We are eager to know you and your child better in the coming weeks. Please help us get started by sharing with us some important things about your child. We encourage you to talk with us at any time and to provide all information that may help us to teach and care for your child in a more complete way. We look forward to working together as partners in support of your child.

Child’s Name:(Required)

Date:(Required)

Completed By:(Required)

Relationship to Child:(Required)

In a few words, please describe your child:(Required)

Who is part of your child’s family? Please list names of family members and their relationship to the child:(Required)

What are some of your family traditions?(Required)

What are your child’s favorites?

Favorite toys:(Required)

Favorite songs:(Required)

Favorite foods:(Required)

Favorite activities:(Required)

Other:

Are there situations or experiences that upset your child?(Required)

What do you do to comfort him/her when he/she is upset or afraid?(Required)

How does your child communicate with you and other members of your family?(Required)

If already talking, can you understand the words he/she says?(Required)

Do you have any special concerns about your child’s development that you would like to share with us?(Required)

What questions do you have about your child’s upcoming school experience?(Required)

What do you hope your child gains from his/her experience at school?(Required)

How can we best support you in your role as parents?(Required)

How would you like to be contacted by your child’s teachers? Also, please tell us the best times to reach you for non-emergency conversations.(Required)

Any additional thoughts you would like to share?(Required)

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Summer Transition Enrollment Pack

EMERGENCY CONTACTS & AUTHORIZED PICK UP RESPONSES

CHILD MAINTENANCE

GENERAL RELEASE

PHOTOGRAPH/VIDEOTAPE RELEASE

SUMMER TRANSITION - ROSTER INFORMATION FORM

SUMMER TRANSITION - AGREEMENT FORM

SUMMER TRANSITION - FAMILY SURVEY

PROCARE - PARENT GUIDE TO SIGN IN/OUT

HEALTH INFORMATION AND EMERGENCY PERMISSION

TRANSPORTATION AGREEMENT

TRANSPORTATION AGREEMENT FOR SCHOOL AGE USE ONLY

PHOTO RELEASE FORM

SOCIAL MEDIA RELEASE

AUTHORIZATION TO DISPENSE EXTERNAL PREPARATIONS

USDA FOOD PROGRAM

CACFP Meal Benefit Income Eligibility Statement

PART I: Child(ren) or Adult enrolled to receive day care

PART II: Report income for ALL Household Members (Skip this step if participant is categorically eligible as documented in Part 1.) Are you unsure what income to include here? Flip the page and review the charts titled “Sources of Income” for more information.

PART III: Enrollment Information Children Only

PART IV: Signature

PART V: Participant’s Ethnic and Racial Identities (optional)

WIC - A Special Food and Nutrition Education Program for Women, Infants and Children

ALL ABOUT ME AND MY FAMILY

Loganville

Covington

Have Questions?

Summer Transition Enrollment Pack

EMERGENCY CONTACTS & AUTHORIZED PICK UP RESPONSES

CHILD MAINTENANCE

GENERAL RELEASE

PHOTOGRAPH/VIDEOTAPE RELEASE

SUMMER TRANSITION - ROSTER INFORMATION FORM

SUMMER TRANSITION - AGREEMENT FORM

SUMMER TRANSITION - FAMILY SURVEY

PROCARE - PARENT GUIDE TO SIGN IN/OUT

HEALTH INFORMATION AND EMERGENCY PERMISSION

TRANSPORTATION AGREEMENT

TRANSPORTATION AGREEMENT FOR SCHOOL AGE USE ONLY

PHOTO RELEASE FORM

SOCIAL MEDIA RELEASE

AUTHORIZATION TO DISPENSE EXTERNAL PREPARATIONS

USDA FOOD PROGRAM

CACFP Meal Benefit Income Eligibility Statement

PART I: Child(ren) or Adult enrolled to receive day care

PART II: Report income for ALL Household Members (Skip this step if participant is categorically eligible as documented in Part 1.) Are you unsure what income to include here? Flip the page and review the charts titled “Sources of Income” for more information.

PART III: Enrollment Information Children Only

PART IV: Signature

PART V: Participant’s Ethnic and Racial Identities (optional)

WIC - A Special Food and Nutrition Education Program for Women, Infants and Children

ALL ABOUT ME AND MY FAMILY

Loganville

Covington

Have Questions?

BRANFORD – 203-488-5437

CHESHIRE – 203-271-1147

WALLINGFORD – 203-269-5437