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Broadcasters’ Child Development Center Admissions Folder Checklist

_____________________________________________________________________________________

Section 1 – General Administrative Documents

Welcome Letter Parent Contract Admissions Form ACH Agreement Tuition Rates (2018-2019) Center Contact Information Tadpoles Welcome Letter

Section 2 – BCDC’s Internal Forms

Emergency Contact Card Infant / Toddler Development Form Parent Participation Form Directory Permission Form Photograph Permission Form

Section 3 – OSSE’s Required Forms

Health Certificate Oral Health (Dental) Certificate Medical Treatment Authorization Medication Authorization Registration Record; Care Away from Home Travel and Activity Authorization Food Allergy Action Plan

Section 4 – BCDC Policies

Tuition Policy Sickness / Illness Policy BCDC’s Peanut and Tree Nut Policy Medication Policy Inclement Weather Policy Late Policy Room Parent Responsibilities BCDC Calendar

_____________________________________________________________________________________

Please direct questions about this packet to:

Crystal Lewis | Operations Manager Broadcasters’ Child Development Center

3400 International Drive, NW, Box 114 Washington, DC 20008

Phone: (202) 364-8799, ext. 119 Email: [email protected]

PARENT CONTRACT

Last Revision: May 17, 2018

Following are the conditions for enrollment at Broadcasters’ Child Development Center:

1. Changes in Registration Information: I will notify BCDC’s administration immediately of any changes pertaining to

the information kept on file for my child.

2. Deposits: Upon receiving a written offer to enroll at BCDC, I agree to pay the $550 deposit and first month’s tuition

within one week of acceptance. I understand that my deposit will be refunded when I withdraw my child from the center

providing that I issue proper notice, return my key fobs and have paid any outstanding balance owed to BCDC. I also

understand that a deposit of $275.00 is required upon enrollment of a sibling.

3. Enrollment Procedures: Re-enrollment will occur for each child every April. If I wish to withdraw my child during the

months of June, July, August or September, I understand that two months written notice is required or I will forfeit my

deposit. In the event that I wish to withdraw my child at any other time, I will give the center written notice at least one

month prior or forfeit my deposit. BCDC does not prorate tuition for partial months when leaving the Center. If your

child will be on vacation for an extended period of time, tuition payment is still required.

4. Tuition Procedures: I agree to pay tuition by the first school day of each month. I understand that a $5.00 daily

delinquent fee will be due after a 5 school day grace period and assessed daily thereafter until tuition is paid in full. If I

am late two (2) times within a six (6) month period I will participate in the auto pay program. Because the Center must

pay for checks returned due to insufficient funds, I agree to pay all bank fees.

5. Child Illness: upon being notified that my child is ill, I agree to arrange to have him/her picked up immediately. I also

agree to follow the BCDC sick policy.

6. Contract Hours and Late Fees: I agree to contract for care between 8:00 am and 6:00 pm. I understand that if I do not

abide by my contract hours, I may be subject to penalties determined by the Director which may include, but are not

limited to, penalty fees, suspension or termination, as described in the Late Pick-Up Policy.

7. Drop-off Policy: I agree to drop off my child prior to 11:00 am, understanding that late arrival is disruptive to the

classroom and can be difficult for the child. Exceptions will be made for doctor’s appointments or when given approval

by the Center Director in advance. Failure to abide by the drop-off policy may result in my child not being admitted that

day, suspension or termination of enrollment.

8. Dismissal from BCDC: The Center reserves the right to take any appropriate action, up to and including the right to

terminate our child’s enrollment if any of the following occur:

a. The Director and Board Chair determines that our child’s behavior threatens the physical or mental health of

other children or staff in the Center

b. Tuition is 15 days or more late

c. Contract hours are not abided by

d. Failure to keep our child’s health and immunization records current

e. The program is unable to meet the developmental or social needs of our child

f. The Director and Board Chair determines that any individual responsible for our child has engaged in

inappropriate conduct toward any other member of the Center community.

9. Outside Consultants: I grant permission to have my child interviewed, observed or tested by outside consultants as seen

fit by the Director with advance notice given.

I agree to abide by the above mentioned conditions of enrollment

Child’s Name: __________________________ Parent/Guardian’s Signature: _____________________________

Date: _________________________________ Parent/Guardian’s Name (Print): _________________________

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)

Company Company Name ID Number I (we) hereby authorize , hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account / Savings Account (select one) indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. Depository Name Branch City State Zip Routing Account Number Number This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. Name(s) ID Number (Please Print) Date Signature _____________________________________________________________ NOTE: ALL DEBIT AUTHORIZATION MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

Broadcasters' Child Development Center 52-1197310

Broadcasters' Child Development Center

Broadcasters’ Child Development Center Center Contact Information

_____________________________________________________________________________________

Kim Mohler | Executive Director Phone: (202) 364-8799, Ext. 112

Email: [email protected]

Ravion Wynn | Assistant Director Phone: (202) 364-8799, Ext. 110 Email: [email protected]

Crystal Lewis | Operations Manager

Phone: (202) 364-8799, Ext. 110 Email: [email protected]

_____________________________________________________________________________________

BCDC’s Board of Directors

Stephanie Folarin Margie Yeager Andrew Paciorek Chris Krahe Co-Chair Co-Chair Treasurer Secretary

BCDC Parent Former BCDC Parent BCDC Parent BCDC Parent ___________________________________________________________________________________

Please note, BCDC is uniquely housed in a building that has addresses on two separate streets. We have found it helpful to use these two addresses in different ways; one address is used for business purposes, and the second address is used for mail, shipping and when providing driving directions to someone who may be using a GPS. We are providing these two addresses for your convenience:

Our Business Address:

Broadcasters’ Child Development Center 3400 International Drive, Box 114

Washington, DC 20008

Our Mailing and GPS-Friendly Address: Broadcasters’ Child Development Center

3007 Tilden Street, NW Washington, DC 20008

www.bcdconline.org

###

Dear BCDC Families, Keeping you involved with the school and your child’s daily experiences has always been a priority of ours. We use a program called Tadpoles to communicate with parents. From Tadpoles, teachers can send photos and videos periodically to allow you to see a glimpse into your child’s day! Teachers will also be creating a daily report for each child. This daily report will keep you informed of the daily activities, learning experiences, and care events for your child each day. All photos, videos, and daily reports are emailed to you directly and you can also access them via the free Tadpoles Parent app, available on Apple and Android devices, or online at www.tadpoles.com as well! The daily report is sent when your child is checked out at pick up time on the iPad or by 7pm. Your Tadpoles account will become a valued memory book, as it stores all information sent for your child within your account, allowing you to always go back in time and look at the precious memories and photos of your child. To create your account online, please use the following steps:

- Visit www.tadpoles.com and click log in at the top right - Select Parents on the left - Choose sign up under “use a tadpoles account” - Use the email address that is currently on file with our school

o If it’s a Gmail account, you can sign right in to the account o If it’s not a Gmail account, enter your email, choose submit and check your email for the

link to establish your password

The same login information will be used to access your account via the free Tadpoles Parent app as well. If you need further assistance establishing your account, please visit help.tadpoles.com for additional information. Tadpoles will continue to strengthen our home-to-school connection. Not only does it allow us to send you real time information about your child’s day, but it also enhances your ability to communicate with the school as well. From your Tadpoles parent account, via the app or web, you will be able to enter in morning drop off notes for your child’s teachers, mark your child absent, and/or add any additional notes to be communicated to the school. Each classroom is equipped with an iPad which will be specifically used for the Tadpoles program and My Teaching Strategies. If you see a teacher on a tablet, rest assured, they are only using the device to input information into Tadpoles or MyTeachingStrategies. The devices are restricted, giving teachers limited access to only the Tadpoles & MyTeachingStrategies applications. We consider all information captured within Tadpoles to be a private communication between our school and our families. No personal information is shared with any external parties and as a parent you will only receive information specifically about your child. The confidentiality of all information is maintained through the security features of the Tadpoles software. We are very excited to begin utilizing Tadpoles and know it will positively impact the engagement of our families and our home-to-school connection. We feel confident that you will love Tadpoles and the level of involvement it allows you to have with your child’s daily experiences while at our school. We are happy to answer any questions or concerns you may have about this exciting program! Thank you for your patience during this transition!

http://www.tadpoles.com/

http://www.tadpoles.com/

Infant/Toddler Development Form

Child’s name: _____________________________________________ Date of birth: _______________________ (first) (middle) (last) (month) (day) (year) Prenatal and Delivery Information Pregnancy: Normal? yes _____ no _____ Term ____________________________________________ Labor and delivery: Normal? yes _____ no _____ Time ______________________________________ Complications, if any: _______________________________________________________________________ If C-section, why? _________________________________________________________________________ Infant distress Causes:______________________________________________________________________ Diagnosis: ___________________________________________________________________ Any lasting trauma? ___________________________________________________________ General Health Is your child susceptible to:

Stomach problems ______________ Colds __________________ Allergies ______________________ explain: _________________________________________________________________________________ ________________________________________________________________________________________ Immunization dates (if necessary, change to reflect the schedule your pediatrician follows) 2 mos. __________ 5 mos. ____________ 7 mos. __________ 9 mos. ______________ Developmental History weight at birth _______________ present weight _________________ height at birth ________________ present height __________________ has your child’s growth been consistent? yes ____ no _____ if no, why? _______________________________________________________________________________ Please give age: Held head up ________________ Rolled over ________________

Sat up (assisted ) _____________ (Unassisted) _______________ Stood up ____________________ Walked ___________________

Feeding: Breast fed? __________ How long? ________________ Satisfactory? __________ When weaned? _________________ Bottle, formula: _____________________________ Solids, when begun? _________________________________________________________________ Any allergies? ______________________________________________________________________ Verbalization (please give age) Cooing-gurgling ____________ Mimic sounds _______________ First words _____________ What? __________________________________________________ Habits and Routines Feeding schedule: please complete based on your child’s home schedule: breakfast lunch dinner What time? _______________ _______________ _________________ For how long? _______________ _______________ _________________ Bottle, food or both? _______________ _______________ _________________ Where? _______________ _______________ _________________ Utensils used _______________ _______________ _________________ Is your child used to mid-morning or mid-afternoon snacks? ______________________________________________ What type of food? _________________________________________________________________________ Any other information you think we ought to know about your child’s eating habits: ___________________________ _______________________________________________________________________________________________ Likes? _________________________________________________________________________________________ Dislikes? _______________________________________________________________________________________ Toilet Habits Diapers ________ Training pants ________ Age training began ______________________ success rate ____________________________ Would you like for us to follow your training schedule? yes _____ no _____ Terms used for: Toilet: ________________ urination: ______________ Bowel movement _____________________

Bowel movements Average number per day _______ Consistency: solid ________, soft ________, very soft ___________ Causes of diarrhea? ________________________________________________________________________ Tends to get constipated? __________ why? ___________________________________________________ Cure: ___________________________________________________________________________________ Sleeping Habits Bedtime: any problems going to sleep at night? _________________________________________ awakens happy_____________ awakens grouchy _________________ Naps (give approximate time and length): a.m. ___________________ p.m. ___________________________ any problems? ____________________________________________________________________________ Special routines: rocked ______ blanket ______ book ______ music ______ doll/toy ___________ other, explain __________________________________________ Sleeps on back? _______________ on stomach? _________________ dark room? ___________________ Discipline usual method of discipline __________________________________________________________________ who is responsible for discipline? _____________________________________________________________ reward for good behavior? __________________________________________________________________ any special problems? ______________________________________________________________________ Playing Habits Alone: what is your child used to playing with? _________________________________________________ Attention span (how long)? __________________________________________________________________ Where does he/she play: crib? ______ playpen? _______ other, explain ________________________ What types of games does your child like? peek-a-boo ______ hide and seek ______ patty-cake ______ singing _____ others, list __________________________________________________________________ Is your child accustomed to sharing? _________________________________________________________________ Do you foresee any problems regarding placing your child in day care (e.g., regression, separation problems, change in eating or sleeping routines, etc.)? _________________________________ _____________________________________________________________________________________________ How can we help make the transition easier? ___________________________________________________ _____________________________________________________________________________ Revised 3/1/09

BCDC prides itself on the commitment and contributions parents make to our Center. Please indicate below whether and how you might like to volunteer at BCDC.

(Please Print)

Child’s/Children’s Name(s):________________________________________________________

Last Revision: 5/17/18

Parent’s Name:______________________ Daytime Phone:______________________ Evening Phone:______________________ Email:______________________________ __ Fundraising __ Grant Research & Grant Writing __ Facility Maintenance; General Repairs (Painting, carpentry, toys, books, playground maintenance etc.) __ Center Accreditation Support __ Center Events (Fall picnic, holiday party, achievement picnic, etc.) __ Computer & IT Support __ Room Parent __ Other ____________________________

Parent’s Name:______________________ Daytime Phone:______________________ Evening Phone:______________________ Email:______________________________ __ Fundraising __ Grant Research & Grant Writing __ Facility Maintenance; General Repairs (Painting, carpentry, toys, books, playground maintenance etc.) __ Center Accreditation Support __ Center Events (Fall picnic, holiday party, achievement picnic, etc.) __ Computer & IT Support __ Room Parent __ Other ____________________________

Parent 1 Parent 2

This form provides BCDC with permission to publish your family’s information in the Center directory. The purpose of the directory is to provide enrolled families with contact information which can be used for arranging playdates, birthday parties, etc. By signing this form, you agree not to sell, share or otherwise disseminate this information in any unauthorized manner.

Please complete one form for each enrolled child, fill in all appropriate areas and sign below.

Please Choose One Option: [ ] I CONSENT [ ] I DO NOT CONSENT

I agree to abide by the usage and privacy policies outlined on this authorization form. Parent’s Name (Print): ____________________________________ Parent’s Signature: _______________________________________ Date: __________________


Child’s Name: _________________________________________________________ Parent’s Name: ________________________________________________________ Parent’s Daytime Phone #: (______) _________ — ____________________ Email Address: ________________________________________________________ Parent’s Name: ________________________________________________________ Parent’s Daytime Phone #: (______) _________ — ____________________ Email Address: ________________________________________________________ Street Address: ________________________________________________________ City: ______________________ State: _____ Zip Code: ___________ Home Telephone #: (______) _________ — ____________________


I authorize Broadcasters' Child Development Center (BCDC) to photograph and/or record audio and video of my child while he/she is participating in BCDC programs and activities. I further authorize BCDC to print, publish or otherwise disseminate such photograph(s) and/or audio and video of my child via printed materials, classroom or other BCDC on-site displays, any website operated or maintained by BCDC (e.g., www.bcdconline.org ), or by other means. I understand that BCDC will not publish my child’s name or any other identifying or private information. I also understand that such dissemination shall be for the purpose of furthering the educational and/or to promote BCDC.

Please Choose One Option: [ ] I AUTHORIZE [ ] I DO NOT AUTHORIZE

We also welcome you to direct questions about photo usage to:

Kim Mohler | Executive Director Phone: (202) 364-8799, Ext. 112

Email: [email protected] Child’s Name: _____________________________________________________________ Parent/Guardian’s Name (Print): _______________________________________________ Parent/Guardian’s Signature: ___________________________ Date: ________________

DDIISSTTRRIICCTT OOFF CCOOLLUUMMBBIIAA UUNNIIVVEERRSSAALL HHEEAALLTTHH CCEERRTTIIFFIICCAATTEE IINNSSTTRRUUCCTTIIOONNSS This form replaces all forms dated before February 24, 2009. This District of Columbia Universal Health Certificate (DCUHC) will be used for entry into Child Care Facilities, Head Start and DC public, private and parochial schools. Exception: It cannot be used to replace EPSDT forms or the Department of Health Oral Health Assessment Form. The DCUHC was developed by the DC Department of Health and follows the American Academy of Pediatrics (AAP) guidelines for child and adolescent preventive health care; from birth to 21 years of age. This form is a confidential document, consistent with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for health providers, and the Family Educational Rights and Privacy Act of 1974 (FERPA) for educational institutions. General Instructions: Please use a black ball point pen when completing this form. Part 1: Child’s Personal Information: Parent or Guardian: Please complete all of your child’s personal information including the child’s last name, first and middle name, date of birth and gender. Also include your name, phone number, home address, the ward in which the address is located, and the name and phone number of an emergency contact in case you cannot be reached. Provide the name of the school or child care facility. Check the box that describes your child’s type of health insurance coverage. If the child’s type of insurance coverage is not listed, check “other” and write the type of coverage in the space provided. Write the name of your child’s primary care provider (doctor). If your child does not have a primary care provider, write “none” in the space provided. This form will not be complete without the parent or guardian’s signature in Part 5. Part 2: Child’s Health History, Examination & Recommendations: (To be completed by the health care provider). Please mark all relevant boxes. • Date of Health Exam: All children must have a physical examination by a physician or certified nurse practitioner as per the AAP Guidelines. The date entered here

must indicate the date of the examination. • WT: Child’s weight in either pounds (LBS) or kilograms (KG); HT: Child’s height in either inches (IN) or centimeters (CM). • BP: If a child is three years of age or older, write the blood pressure value in the box and check if normal or abnormal. If abnormal, provide an explanation and

resolution in Part 2: Section A. • Body Mass Index (BMI): If the child is 2 years of age or older, the BMI has to be calculated and recorded inclusive of percentile. • HGB/HCT: Hemoglobin (HGB) or Hematocrit (HCT) is required for Head Start children. Also, anemia screening is recommended for menstruating adolescents

based on AAP guidelines. Please record blood level and indicate which test was performed by circling HGB, HCT or both. • HEALTH CONCERNS: The health care provider must perform the following health screens: asthma, seizure, diabetes, language, developmental/behavioral and

other disorders that may require special health care needs.” For any of the health screens where there are “HEALTH CONCERNS,” the health care provider must check the box indicating that the proper referral has been made or the child is currently being treated (Rx) for the concern. IF there are NO/NONE “HEALTH CONCERNS”, then check the ‘NO” or None” box in each health screening area.

• SPECIAL NOTE: “Annual Dentist Visit” – for children three years of age and older, the health care provider must indicate whether a dentist has screened or examined the child within the last 12 months. If “No”, the child should be referred to a dentist.

• A: Please note any significant health history, conditions, communicable illness and restrictions that may affect the child’s ability to perform in a school-related activity or program or mark “NONE”.

• B: Please note any significant allergies that may require emergency medical care at a school-related activity or program or mark “NONE”. • C: Please note any long-term medications, over-the-counter drugs or special care requirements at a school-related activity or program or mark • “NONE”. • SPECIAL NOTE: Please note any medications or treatments required at a school-related activity or program in Part 2: Section C and complete a Physician’s

Medication Authorization Order and attached it to the health certificate. Part 3: Tuberculosis & Lead Exposure Risk Assessment & Testing:

• TUBERCULOSIS (TB) RISK ASSESSMENT: Perform risk assessment for TB as defined by the AAP Tuberculin Skin Test Recommendations for Infants, Children and Adolescents in the 2006 AAP RED BOOK, 27th Ed., page 682. Current DC regulations require one TST (Tuberculin Skin Test) for all children entering child care or school; whichever comes first. TST is also required for all children who are assessed as HIGH RISK OF EXPOSURE. Please note the test and mark the test outcome (negative or positive). If the TST is positive, then mark the chest X-Ray outcome (CXR) and whether the child was treated. All positive TSTs must be reported to the DC T.B. Control Program on 202-698-4040. • LEAD EXPOSURE RISKS: DC law requires that all children are tested between 6 and 14 months of age and again between 22 and 26 months. DC law also requires that if a child is more than 26 months old and has not yet been tested for lead exposure, that child must be screened twice prior to age 6. Please document both the “Date” and “Result” of most recent lead test. Please indicate if “Pending.” “Pending” results will be valid for two months from date of testing and will not exclude a child from school-related activity or program. ALL lead tests must be reported electronically by labs to the DC Childhood Lead Poisoning Prevention Program. For detailed instructions, call 202-654-6036/6037. Providers may fax results to: 202-481-3770. Part 4: Required Provider (physician or nurse practitioner) Certification and Signature: The provider will respond by marking “Yes” or “No” to the following statements: The child was appropriately examined with a review of the health history; The child is cleared for competitive sports (based on the assessment and consistent with the AAP Pre-participation Physical Evaluation 2nd Ed. (1997; and The child has received age-appropriate screenings (in accordance with AAP and EPSDT guidelines) within the current year. If “No” is marked, explain the reason in the space provided. All information will be kept confidential. Part 5: Required Parent/Guardian Signatures. (Release of Health Information). The parent or guardian must print their name; provide a signature and the date. By signing this section the parent or guardian gives permission to the health provider to share the health information on this form with the child’s school, child care facility, camp or appropriate DC Government agency.

Forms are available online at www.doh.dc.gov

http://www.doh.dc.gov/

DDIISSTTRRIICCTT OOFF CCOOLLUUMMBBIIAA UUNNIIVVEERRSSAALL HHEEAALLTTHH CCEERRTTIIFFIICCAATTEE

2 Part 6: IMMUNIZATION INFORMATION General Instructions: Please use black ball point pen when completing form Child/Student Personal Information: Print clearly child/students last name, first name, and middle name/initial. Enter date of birth as mm/dd/yr. Indicate sex of child/student by checking female or male. Indicate name of school or child care facility child attends.

Section 1: Immunization Information – Enter clearly date (mm/dd/yy) vaccine(s) administered or attach equivalent copy with provider’s signature and date. As required by D.C. Law 3-20, “Immunization of School Students Act of 1979” and DCMR Title 22, Chapter 1 (revised May 2, 2008), the following immunizations are required.

Instructions: Find the age of the child/student in the column labeled “Child’s Current Age”. Read across the row for each required vaccine. The number in the box is the number of doses required for that vaccine based on the CURRENT age or grade level of the child. The age range in the column does not mean that the child has until the highest age in that range to meet compliance. Any child whose age falls within that range must have received the required number of doses based on his/her CURRENT age in order to be in compliance.

Vaccine types and dosage numbers required for children enrolled in Child Care Programs1, 2

Child’s Current Age DTa

P/D

TP/D

T

Polio

Hib

7

MM

R8

Var

icel

la9

(Chi

cken

pox)

Hep

atiti

s B10

Hep

atiti

s A11

Pneu

moc

occa

l C

onju

gate

12

Men

ingo

cocc

al

Hum

an

Papi

llom

aviru

s (H

PV)

Less than 2 months 0 0 0 0 0 1 0 0 0 0 2 – 3 months 1 1 1 0 0 1 0 1 0 0 4 – 5 months 2 2 2 0 0 2 0 2 0 0 6 – 11 months 3 3 2 / 3 0 0 3 0 3 0 0 12 – 14 months 3 3 3 / 4 1 1 3 1 4 0 0 15 – 23 months 4 3 3 / 4 1 1 3 1 4 0 0 24 – 47 months 4 3 3 / 4 1 1 3 2 4 0 0 48 – 59 months 53 46 3 / 4 2 2 3 2 4 0 0

Vaccine types and dosage numbers required for children enrolled in Public, Charter, Parochial and Private Schools1, 2

Grade Level DTa

P/D

TP/D

T/

Td/T

dap

Polio

6

Hib

MM

R8

Var

icel

la9

(Chi

cken

pox)

Hep

atiti

s B10

Hep

atiti

s A11

Pneu

moc

occa

l C

onju

gate

Men

ingo

cocc

al13

Hum

an

Papi

llom

aviru

s14

(HPV

)

Grade (Ungraded) Grades K – 5 (5 – 10 yrs) 53, 4 4 0 2 2 3 2 0 0 0 Grades 6 - 12 (11 – 18+ yrs) 64, 5 4 0 2 2 3 2 0 1 3

1Spacing: Doses must be appropriately spaced and given at appropriate age. Vaccine doses administered up to 4 days before minimum interval or age are counted as valid. Exception: Two live virus vaccines that are not administered on same day, must be separated by a minimum of 28 days. 2Exemptions: Medical exemptions from immunizations may be granted for valid reasons with proper documentation from health care provider (Section 2). Blood titers may be obtained in lieu of immunizations (Section 3). A copy of the lab report must be submitted to school/child care facility. Documentation for religious exemptions must be submitted by parent/guardian to the school/child care facility. 3DTP/DTaP: Five (5) doses of DTP/DTaP are required at 4 years of age for school entry unless 4th dose was given on or after the 4th birthday. Interval between dose 4 and dose 5 of DTP/DTaP must be 6 months. 4Td/Tdap: Three (3) doses of Td required if primary series started after 7th birthday. If >11 years old, one of three doses must be tetanus, diphtheria, and pertussis (Tdap) vaccine dose. Tdap booster required five years after last dose of tetanus, diphtheria-containing vaccine. Td booster required every 10 years. 5Tdap: Student must meet the minimum prior requirement for the 4th or 5th doses of DTP/DTaP vaccine and have one (1) dose of Tdap. 6Polio: Four doses are required at age 4 for school entry, unless the third dose of an all-IPV or all-OPV schedule is given on or after the 4th birthday, in which only 3 doses are needed. However, if the sequential or mixed IPV/OPV schedule was used, four doses are required to complete the primary series. Polio is not routinely given for students > 18 years of age. 7HIB: The number of primary doses is determined by vaccine product and age the series begins. The last dose of Hib must be administered on or after 12 months of age, however, if only one (1) dose is given, it must be administered on or after 15 months of age. The vaccine is not required for students 5 years of age and older. 8MMR: Second dose required at 4 years of age. First dose must be given on or after the first birthday. Second dose may be given one month after the first dose. MMR and Varicella must be given on the same day or separated by 28 days. 9Varicella: Second dose required at 4 years of age. First dose must be given on or after the first birthday. If first dose given between 12 months and 12 years of age, second dose is given 3 months after first dose; if first dose is given at > 13 years, 2nd dose may be given one month after first dose. The Varicella vaccine is not required for a student who has a history of chickenpox verified by a primary care provider and includes the month and year of disease. 10Hepatitis B: If monovalent hepatitis B vaccine is given in conjunction with a combination vaccine, i.e. DTaP-IPV-Hepatitis B, four doses of hepatitis B is acceptable; however, dose 3 or 4 must be given at age 24 weeks or later and at least 8 weeks after the previous dose. If monovalent hepatitis B vaccine is administered, dose 3 must be given at least 16 weeks after dose one and at least 8 weeks after dose 2. For students 11-15 years old, a clearly documented 2-dose adult hepatitis B vaccine (Recombivax) is acceptable. 11Hepatitis A: Required for students born on or after January 1, 2005. 12Pneumococcal: The number of pneumococcal doses required depends on the student’s current age and the age when the first dose was administered. Administer 1 dose to healthy children aged 24 through 59 months who are not completely vaccinated for their age. The vaccine is not required for students 5 years of age and older. 13Meningococcal: Required at age 11 years of age and older. 14HPV: Required for students entering the sixth grade for the first time. Information concerning human papillomavirus (HPV) and the HPV vaccine must be provided to parent/guardian or student. A parent/guardian may sign a form approved by the Department of Health to “Opt-Out”.

Section 2: Medical Exemption – Complete this section if there exist a medical contraindication which prevents the child from receiving one or more immunizations in a timely manner consistent with D.C. Law 3-20 & ACIP recommendations. Check all contraindicated vaccines and provide a reason for contraindication. If the medical exemption is permanent, check appropriate space. If medical exemption is temporary, check the appropriate space and enter the date it expires. Medical provider must sign, print name or stamp and date this section.

Section 3: Alternative Proof of Immunity – Complete this section if blood titers are used to show proof of immunity. Check vaccine(s) which blood titer were obtained. Attach a copy of the titer results. Medical provider must sign, print name or stamp and date this section.


Part 1: Child’s Personal Information Parent/Guardian: Please complete Part 1 clearly and completely & sign Part 5 below. Child’s Last Name: Child’s First & Middle Name: Date of Birth: Gender:

M F

Race/Ethnicity: White Non Hispanic Black Non Hispanic

Hispanic Asian or Pacific Islander Other______________

Parent or Guardian Name: Telephone:

Home Cell Work

Home Address: Ward:

Emergency Contact Person: Emergency Number:

Home Cell Work

City/State (if other than D.C.) Zip code:

School or Child Care Facility:

Medicaid Private Insurance None

Other ________________________________

Primary Care Provider (PCP):

Part 2: Child’s Health History, Examination & Recommendations Health Provider: Form must be fully completed.

DATE OF HEALTH EXAM: WT LBS KG

HT IN CM

BP: (>3 yrs) NML ABNL

Body Mass Index (>2 yrs) (BMI)___________

%______________

HGB / HCT (Required for Head Start)

Vision Screening Right 20/____ Left 20/____

Glasses

Referred

Hearing Screening

Pass________ Fail________ Referred

HEALTH CONCERNS: REFERRED or TREATED HEALTH CONCERNS: REFERRED or TREATED

Asthma NO

YES

Referred Under Rx Language/Speech NONE

YES Referred Under Rx

Seizure NO

YES

Referred Under Rx Development/ Behavioral

NONE


Diabetes NO

YES

Referred Under Rx Other____________ NONE


ANNUAL DENTIST VISIT: (Age 3 and older): Has the child seen a Dentist/Dental Provider within the last year? YES NO Referred A. Significant health history, conditions, communicable illness, or restrictions that may affect school, child care, sports, or camp.

NONE YES, please detail: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

B. Significant food/medication/environmental allergies that may require emergency medical care at school, child care, camp, or sports activity.

NONE YES, please detail: ___________________________________________________________________________________

_____________________________________________________________________________________________________________ C. Long-term medications, over-the-counter-drugs (OTC) or special care requirements.

NONE YES, please detail (For any medications or treatment required during school hours, a Physician’s Medication Authorization Order

should be submitted with this form)

______________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________

Part 3: Tuberculosis & Lead Exposure Risk Assessment & Testing: TB RISK ASSESSMENTS

HIGH LOW

Tuberculin Skin Test (TST) DATE:

NEGATIVE POSITIVE

If TST Positive CXR NEGATIVE CXR POSITIVE TREATED

Health Provider: POSITIVE TST should be referred to PCP for evaluation. For questions, call T.B. Control: 202-698-4040

LEAD EXPOSURE RISKS

YES NO

LEAD TEST DATE:

RESULT: Health Provider: ALL lead levels must be reported to DC Childhood Lead Poisoning Prevention Program: Fax: 202-481-3770

Part 4: Required Provider Certification and Signature YYEESS NNOO TThhiiss cchhiilldd hhaass bbeeeenn aapppprroopprriiaatteellyy eexxaammiinneedd && hheeaalltthh hhiissttoorryy rreevviieewweedd.. AAtt ttiimmee ooff eexxaamm,, tthhiiss cchhiilldd iiss iinn

ssaattiissffaaccttoorryy hheeaalltthh ttoo ppaarrttiicciippaattee iinn aallll sscchhooooll,, ccaammpp oorr cchhiilldd ccaarree aaccttiivviittiieess eexxcceepptt aass nnootteedd aabboovvee..

YYEESS NNOO TThhiiss aatthhlleettee iiss cclleeaarreedd ffoorr ccoommppeettiittiivvee ssppoorrttss..

YYEESS NNOO AAggee--aapppprroopprriiaattee hheeaalltthh ssccrreeeenniinngg rreeqquuiirreemmeennttss ppeerrffoorrmmeedd wwiitthhiinn ccuurrrreenntt yyeeaarr.. IIff nnoo,, pplleeaassee eexxppllaaiinn::

______________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________ Print Name MD/NP Signature Date

Address Phone Fax

Part 5: Required Parental/Guardian Signatures. (Release of Health Information) I give permission to the signing health examiner/facility to share the health information on this form with my child’s school, child care, camp, or appropriate DC Government Agency.

Print Name Signature Date


Student’s Name: ____________________________/_________________________/________________ Date of Birth:_____/_____/________ Last First Middle Mo. /Day/ Yr. Sex: Male Female School or Child Care Facility:______________________________________________________________ Section 1: Immunization: Please fill in or attach equivalent copy with provider signature and date.

IMMUNIZATIONS RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

Diphtheria,Tetanus, Pertussis (DTP,DTaP)

1 2 3 4 5

DT (<7 yrs.)/ Td (>7 yrs.)

1 2 3 4 5

Tdap Booster

1

Haemophilus influenza Type b (Hib )

1 2 3 4

Hepatitis B (HepB)

1 2 3 4

Polio (IPV, OPV)

1 2 3 4

Measles, Mumps, Rubella (MMR)

1 2

Measles

1 2

Mumps

1 2

Rubella

1 2

Varicella 1 2 Chicken Pox Disease History: Yes When: Month____________ Year___________ Verified by:___________________________________________ (Health Care Provider) Name & Title

Pneumococcal Conjugate

1 2 3 4

Hepatitis A (HepA) (Born on or after 01/01/2005)

1 2

Meningococcal Vaccine

1

Human Papillomavirus (HPV)

1 2 3

Influenza (Recommended)

1 2 3 4 5 6 7

Rotavirus (Recommended)

1 2 3

Other

_______________________________________________ _______________________________________ __________ Signature of Medical Provider Print Name or Stamp Date

Section 2: MEDICAL EXEMPTION. For Health Care Provider Use Only.

I certify that the above student has a valid medical contraindication to being immunized at the time against: (check all that apply) Diphtheria: (__) Tetanus: (__) Pertussis: (__) Hib: (__) HepB: (__) Polio: (__) Measles: (__) Mumps: (__) Rubella: (__) Varicella: (__) Pneumococcal: (__) HepA: (__) Meningococcal: (__) HPV: (__) Reason:________________________________________________________________________________________________________________________ This is a permanent condition (___) or temporary condition (___) until ____/____/____. _______________________________________________ _______________________________________ __________ Signature of Medical Provider Print Name or Stamp Date

Section 3: Alternative Proof of Immunity. To be completed by Health Care Provider or Health Official.

I certify that the student named above has laboratory evidence of immunity: (Check all that apply & attach a copy of titer results) Diphtheria: (__) Tetanus: (__) Pertussis: (__) Hib: (__) HepB: (__) Polio: (__) Measles: (__) Mumps: (__) Rubella: (__) Varicella: (__) Pneumococcal: (__) HepA: (__) Meningococcal: (__) HPV: (__) _______________________________________________ _______________________________________ __________ Signature of Medical Provider Print Name or Stamp Date

CONFIDENTIAL FORM- SIDE ONE Please review instruction on side two prior to completing form

Top Copy- School Nurse/DC Oral Health Program 2nd Copy- Oral Health Provider Forms are available online at www.dchealth.dc.gov 5/24/04

DDiissttrriicctt ooff CCoolluummbbiiaa OOrraall HHeeaalltthh ((DDeennttaall PPrroovviiddeerr)) AAsssseessssmmeenntt FFoorrmm Part 1. Child’s Personal Information

Part 2. Child’s Clinical Examination (to be completed by the Dental Provider) Date of Exam __________________________ (Please use key to document all findings on line next to each tooth)

Tooth # Tooth # Tooth # Tooth # 1 _______ 17 ______ A ______ K ______ 2 _______ 18 ______ B ______ L ______ 3 _______ 19 ______ C ______ M ______ 4 _______ 20 ______ D ______ N ______ 5 _______ 21 ______ E ______ O ______ 6 _______ 22 ______ F ______ P ______ 7 _______ 23 ______ G ______ Q ______ 8 _______ 24 ______ H ______ R ______ 9 _______ 25 ______ I ______ S ______ 10 ______ 26 ______ J ______ T ______ 11 ______ 27 ______ 12 ______ 28 ______ 13 ______ 29 ______ 14 ______ 30 ______ 15 ______ 31 ______ 16 ______ 32 ______

Part 3. Clinical Findings and Recommendations (Please indicate in Finding column) Findings Comments 1. Gingival Inflammation Y N 2. Plaque and/or Calculus Y N 3. Abnormal Gingival Attachments Y N 4. Malocclusion Y N 5. Other (e.g. cleft lip/palate) Preventive services completed Yes No Part 4. Final Evaluation/Required Dental Provider Signatures

Part 5. Required Parent/Guardian Signatures

Child’s Last Name Child’s First & Middle Name Date of Birth Gender:

M F

School or Child Care facility:

Parent/Guardian Name Telephone1: Home Cell Work Home Address: Ward

Emergency Contact: Telephone2: Home Cell Work City/State (if other than D.C.) Zip code:

Race/Ethnicity: White Non Hispanic Black Non Hispanic Hispanic Asian or Pacific Islander Other_________________

Primary Care Provider (Medical):

Dentist/Dental Provider: Medicaid Private Insurance None

Other ________________________________

This child has been appropriately examined. Treatment is complete. is incomplete. Referred to ______________________ DDS/DMD Signature Print Name Date Address

Phone Fax

Parent or Guardian Release of Health Information. I give permission to the signing health examiner or facility to share the health information on this form with my child’s school, childcare, camp, or Department of Health PRINT NAME of parent or guardian SIGNATURE of parent or guardian Date

Key (Check Appropriate) S - Sealants X - Missing teeth

Restoration Non-restorable/ Extraction1D-One surface decay UE- Unerupted Tooth 2D-Two surface decay 3D-Three surface decay 4D-More than three surface decay

CONFIDENTIAL FORM- SIDE ONE Please review instruction on side two prior to completing form

Top Copy- School Nurse/DC Oral Health Program 2nd Copy- Oral Health Provider Forms are available online at www.dchealth.dc.gov 5/24/04

Instructions For Completion of Oral Health Assessment Form: District of Columbia Child Health Certificate This Form replaces the Dental Appraisal Form used for entry into DC Schools, all Head Start programs, Childcare providers, camps, after school programs, sports or athletic participation, or any other District of Columbia activity requiring a physical examination. The form was developed by the DC Department of Health and follows the American Academy of Pediatric Dentistry (AAPD) Guidelines on Mandatory School-Entrance Oral Health Examinations. AAPD recommends that a child be given an oral health exam within 6 months of eruption of the child’s first tooth and no later than his or her first birthday. The DC Department of Health recommends that all children 3 years of age and older have an oral health examination performed by a licensed dentist and have the DC Oral Health Assessment Form completed. This form is a confidential document. Confidentiality is adherent to the Health Insurance Portability and Accountability Act of 1996 (HIPPA) for the health providers, and the Family Education Rights and Privacy Act (FERPA) for the DC schools and other providers. General Instructions: Please use black ball point pen when completing this form. Part 1: Child’s Personal Information Please complete all sections including child’s race or ethnicity. Please indicate the ward of your home address. List primary care provider, dental provider, and type of dental insurance coverage. If child has no dental provider and is uninsured, then please write “None” in each box. This form will not be complete without Parent or Guardian signature in Part 5. Part 2: Child’s Clinical Examination: Dental Provider: Form must be fully completed. The Universal Tooth Numbering System is used. Please use key to document all findings for each tooth. An ‘X’ signifies a missing tooth (teeth) with no replacement; non-restorable/extraction; UE: unerupted tooth; S: Sealants; Restoration; 1D: one surface decay; 2D: two surface decay; 3D: three surface decay; 4D: more then three surface decay

- The Key should be used to designate status for each tooth at time of examination on the Oral Health Assessment Form. - If a portion of an existing restoration is defective or has recurrent decay, but part of the restoration is intact, the tooth should be

classified as a decayed tooth. If one surface has decay, then mark as 1D; if two surface has decay then mark as 2D. - Key UE: unerupted, does not apply to a missing primary tooth when a permanent tooth is in a normal eruption pattern.

Part 3: Clinical Findings and Recommendations

- Circle Yes or No in Findings Column - For Yes, please explain in the Comments Section. 1- Advance periodontal conditions (pockets etc., will be noted under gingival inflammation). 1- Gingival inflammation adjacent to an erupting tooth is NOT noted. 1- Inflammation adjacent to orthodontically banded teeth or a dental appliance – whether fixed or removable is noted. 2- Indicate if there is sub and/or supra gingival plaque and or calculus and areas where present. 3- All gingival tissues must be free of inflammation e.g. gingiva is pale pink in color and firm in texture for a finding of 'NO' to be

recorded. 3- Frenum attachments labial, sublingual, etc., will be noted under the Abnormal Gingival Attachment Indicator Code if they are the cause of a specific problem- e.g., spacing of central incisors, speech impediment, etc. 4- Status of orthodontic condition should be noted under Malocclusion. Classification of occlusion is: Class I, Class II, Class III, an

overbite, over jet, cross-bite or end to end. 5- Other is to be used, together with comments, for conditions such as cleft lip/palate. - Indicate whether oral health preventive services such as prophylaxis, sealant and or fluoride treatment have been administered.

Part 4. Final Evaluation/Required Dental Provider Signature; Indicate whether the child has been appropriately examined and if treatment is complete. If treatment is incomplete refer patient for follow up care. Dentist must sign, date, and provide required information.

Part 5 Required Signatures. This Form Will Not Be Complete Without Parent or Guardian Signature & Date The parent or guardian must print, sign, and date this part. By signing this section the parent or guardian gives permission to the dentist or facility to share the oral health information on this form with the child’s school, childcare, camp, Department of Health, or the entity requesting this document. All information will be kept confidential.

810 First Street, NE, 4th floor, Washington, DC 20002 Phone: 202.727.1839 Fax: 202.727.8166 www.osse.dc.gov

PLEASE TYPE OR PRINT

AUTHORIZATION FOR CHILD’S EMERGENCY MEDICAL TREATMENT If my child ____________________________________, born on ______________________, becomes ill or involved in an accident and I cannot be contacted, I authorize the following hospital or physician to give the emergency medical treatment required: Hospital: Address: or: Physician: M.D. Telephone No: (Area Code) Address: I give permission to ___________________________________________________________, located at Name of Facility or Caretaker

___________________________________________________________, to take my child for treatment. I accept responsibility for any necessary expense incurred in the medical treatment of my child, which is not covered by the following: Health Insurance Company: Name of Policy Holder: Relationship to Child: Policy Number: Coverage: Medicaid Number: State: DC MD VA Child’s Known Allergies or Physical Conditions: Signature: Relationship to Child: Address: Telephone No: Home Business Pager/Cell Phone

Date:

Month/Day/Year

Date Updated: Month/Day/Year

810 First Street, NE, 4th floor, Washington, DC 20002

Phone: 202.727.1839 Fax: 202.727.8166 www.osse.dc.gov


Medication Authorization Form

Pursuant to Title 29 of the District of Columbia Municipal Regulations (DCMR), Section 377.1; “No Child

Development Facility may provide medicine or treatment, with the exception of emergency first aid, to any child,

unless the Facility has obtained a written medical order or prescription from the child’s licensed health care

practitioner and the written consent of the child’s parent (s) or guardian (s).”

Pursuant to Title 29 of the District of Columbia Municipal Regulations (DCMR), Section 377.4; “The Facility shall

maintain a medication log, on a form approved by the Director, on which the Facility shall record the date, time of

day, medication, medication dosage, method of administration, and the name of the person administering the

medication, each time any medication is administered to a child.”

Part I: To be completed by the parent/guardian and child’s physician:

I do hereby give permission to __________________________

Name of Facility

to administer the

below noted prescribed medication to my child _________________________ born on __________.

Name of Medication Time/Frequency Dosage Effective Dates

From: To:

From: To:

_____________________________________ Signature of Physician

______________________ Date

_____________________________________ Signature of Parent/Guardian

______________________ Date

Part II: To be completed by the Center Director or designee:

Name of Medication Date Time Given Reactions Staff

Initials

PLEASE RETAIN A COPY FOR YOUR FILE

810 First Street, NE, 4th floor, Washington, DC 20002 Phone: 202.727.1839 Fax: 202.727.8166 www.osse.dc.gov

REGISTRATION RECORD FOR CHILD RECEIVING CARE AWAY FROM HOME

Child: Sex: Male Female Last First M.I. Date of Birth: Home #: Language Spoken At Home______________ Home Address: Number Street Apt. # State ZIP

Father: Home # Last First M.I. Business # Home Address: Number Street Apt. # State ZIP

Business Address: Number Street Apt. # State ZIP

Mother: Home # Last First M.I. Business # Home Address: Number Street Apt. # State ZIP


Relative or Guardian:

______________________________________________

Home #

Last First M.I. Business # Home Address: Number Street Apt. # State ZIP


Person to be contacted in case of an emergency (other than parent/guardian): Relationship to child: Last First M.I. Address: Number Street Apt. # State ZIP Phone #

Designated individual authorized to receive child at end of session: Last First M.I.

Last First M.I.

Last First M.I.

Signature: Relationship to child: Date:

TO BE COMPLETED BY THE FACILITY Date of Admission: _____________________

Date of Withdrawal: ___________ Reason: _________________________________________________________________

810 First Street, NE, 4th floor, Washington, DC 20002

Phone: 202.727.1839 Fax: 202.727.8166 www.osse.dc.gov


TRAVEL AND ACTIVITY AUTHORIZATION

Special 1-time permission for this activity only Blanket permission for all given activities

I, _________________________________________________________ parent/guardian of Name of Parent/Guardian

_________________________________________________________________________give my permission to Name of Child

____________________________________________________________________for my child to participate in

the following activities:

Trips in the van/automobile (facility or parent -owned)

_____________________________________________________________________________________________ Explain planned activity — where and when

Field trips away from the facility

_____________________________________________________________________________________________ Explain planned activity — where and when

I understand that the facility will use the appropriate child restraint devises and abide by all District of Columbia

safety rules when my child is transported in a vehicle. The facility will also notify me each time that my child is to

participate in an activity that would involve transportation.

In addition, if the facility has planned activities outside the fenced area of the facility,

I will allow my child to play outside the fenced area; or _______

I will not allow my child to play outside the fenced area.

This authorization is valid from ______/______/______ to ______/______/______

_____________________________________________ ________________________

Parent/Guardian Signature Date Signed

NOTE: Place on file in child’s folder/record

Food Allergy Action Plan

Place

Child’s Picture Here

Student’s Name:__________________________________D.O.B:_____________Teacher:________________________ ALLERGY TO:______________________________________________________________ Asthmatic Yes* No *Higher risk for severe reaction STEP 1: TREATMENT Symptoms: Give Checked Medication**:

**(To be determined by physician authorizing treatment)

If a food allergen has been ingested, but no symptoms: Epinephrine Antihistamine

Mouth Itching, tingling, or swelling of lips, tongue, mouth Epinephrine Antihistamine

Skin Hives, itchy rash, swelling of the face or extremities Epinephrine Antihistamine

Gut Nausea, abdominal cramps, vomiting, diarrhea Epinephrine Antihistamine

Throat† Tightening of throat, hoarseness, hacking cough Epinephrine Antihistamine

Lung† Shortness of breath, repetitive coughing, wheezing Epinephrine Antihistamine

Heart† Weak or thready pulse, low blood pressure, fainting, pale, blueness Epinephrine Antihistamine

Other† ________________________________________________ Epinephrine Antihistamine

If reaction is progressing (several of the above areas affected), give: Epinephrine Antihistamine

†Potentially life-threatening. The severity of symptoms can quickly change.

DOSAGE Epinephrine: inject intramuscularly (circle one) EpiPen® EpiPen® Jr. Twinject® 0.3 mg Twinject® 0.15 mg (see reverse side for instructions) Antihistamine: give____________________________________________________________________________________ medication/dose/route Other: give____________________________________________________________________________________________ medication/dose/route

IMPORTANT: Asthma inhalers and/or antihistamines cannot be depended on to replace epinephrine in anaphylaxis. STEP 2: EMERGENCY CALLS

1. Call 911 (or Rescue Squad: ____________). State that an allergic reaction has been treated, and additional epinephrine may be needed. 2. Dr. ___________________________________ Phone Number: ___________________________________________ 3. Parent_________________________________ Phone Number(s) __________________________________________ 4. Emergency contacts: Name/Relationship Phone Number(s)

a. ____________________________________________ 1.)________________________ 2.) ______________________

b. ____________________________________________ 1.)________________________ 2.) ______________________

EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILITY! Parent/Guardian’s Signature_________________________________________________ Date_________________________ Doctor’s Signature_________________________________________________________ Date_________________________

(Required)

TRAINED STAFF MEMBERS

1. ____________________________________________________ Room ________ 2. ____________________________________________________ Room ________ 3. ____________________________________________________ Room ________

Once EpiPen® or Twinject® is used, call the Rescue Squad. Take the used unit with you to the Emergency Room. Plan to stay for observation at the Emergency Room for at least 4 hours.

EpiPen® and EpiPen® Jr. Directions

Twinject® 0.3 mg and Twinject® 0.15 mg Directions

Pull off gray activation cap.

Hold black tip near outer thigh (always apply to thigh).

Remove caps labeled “1” and “2.”

Place rounded tip against outer thigh, press down hard until needle penetrates. Hold for 10 seconds, then remove.

Swing and jab firmly into outer thigh

until Auto-Injector mechanism functions. Hold in place and count to 10. Remove the EpiPen® unit and massage the injection area for 10 seconds.

SECOND DOSE ADMINISTRATION: If symptoms don’t improve after 10 minutes, administer second dose: Unscrew rounded tip. Pull

syringe from barrel by holding blue collar at needle base.

Slide yellow collar off plunger.

Put needle into thigh through

skin, push plunger down all the way, and remove.

For children with multiple food allergies, consider providing separate Action Plans for different foods. **Medication checklist adapted from the Authorization of Emergency Treatment form developed by the Mount Sinai School of Medicine. Used with permission.

June/2007

Revised 5/17/18

By action of the Broadcasters’ Child Development Center (BCDC) Board of Directors, our tuition policy was amended to read as follows:

Tuition is due on the first school day of each month. There is a five school-day grace period. After five days, BCDC will assess a penalty of $5.00 per

child, per day to the family’s account. Any family whose payments are late twice within a roll-

ing six month period will be required to participate in the “auto pay” plan. Under this plan, the family’s tuition payment(s) will be automatically deducted from a check-ing account via bank-initiated ACH withdrawal.

This policy was enacted on April 1, 2009. Please Note: The automatic ACH withdrawal plan is enacted upon the family’s completion and submission of an ACH Authorization Form. Please see a member of our staff if you wish to obtain a copy of this form.

Please direct any questions about this policy to:

Crystal Lewis | Operations Manager Phone: (202) 364-8799, Ext. 119 Email: [email protected]

Revised 5/17/18

Young children are quite vulnerable to illness and infections. In order to keep all of our en-rolled children healthy, we ask for your full cooperation in following BCDC’s sick policy, the terms of which are outlined below:

1. Please notify the Center if your child contracts or is exposed to any contagious disease. 2. If your child becomes ill at the Center, a parent or authorized individual will be notified

and asked to immediately pick up the child. 3. Children sent home with any of the symptoms listed below will need to be kept home for

at least 24 hours and must be symptom-free without medication before they can return to the Center:

Fever above 101 degrees Fahrenheit. Children sent home with a fever must be kept home for at least 24 hours without a fever and the use of medication to reduce the fever before they can return to the Center.

Colored mucous coming from eyes, nose, ears or mouth Pink eye, i.e., colored drainage, eye pain and/or redness of the eye. Skin rash - must be diagnosed by a doctor and return to school requires a doctor’s

note Vomiting Diarrhea; Loose or watery stools. Child will be sent home after 2 episodes.

If Diarrhea continues upon return to school, a doctor’s note will be required stating the child is not contagious.

General feeling of illness, tiredness, or inability to participate in daily routines/activities

If deemed necessary by the Director, you will be required to obtain a doctor’s notice stating that any requested tests have been completed and that it is safe for your child to return to the Center. Please direct questions about this policy to:

Ravion Wynn | Assistant Director

Phone: (202) 364-8799, Ext. 110


Peanuts and tree nuts, and any foods containing peanuts or tree nuts and their oils, are not allowed at BCDC. On children’s birthdays or other special occasions, parents should not order or bring any Asian cuisines to BCDC, as they often rely heavily on peanuts and tree nuts, and are therefore subject to a high degree of cross-contamination when prepared, even if the particular dish does not feature pea-nuts, tree nuts or their oils.

Tree nuts include almonds, Brazil nuts, cashews, chestnuts, filberts/hazelnuts, hickory nuts, macadamia nuts,

Mancelona nuts, pecans, pine nuts, pistachios, and walnuts. Common foods containing peanuts or tree nuts include peanut butter and other nut butters (e.g., almond or cashew butter), as well as some breads, cereal, candies, granola bars and other snacks, muffins and cakes. Corn chips and potato chips are often cooked in peanut oil.

Foods whose labels include allergen warnings such as “may contain traces of peanuts,” “processed in a plant

that also processes nuts” or “manufactured on shared equipment” will not be purchased by BCDC for use as snacks. Common foods that may contain trace amounts of peanuts or tree nuts include some breads, cereals, candies, granola bars and other snacks, muffins and cakes. Not all food companies label for trace amounts, so BCDC will order food only after clarifying which products are safe for consumers with peanut or tree nut allergies. Parents, while not prohibited from sending foods with such trace warning labels to BCDC, are strongly discouraged from doing so.

Parents of a child with food allergies must notify the staff in writing as to which BCDC-provided snacks their

child is permitted to eat. Teachers will notify parents of a child with food allergies when birthdays or other special events are planned to ensure that the parents provide an alternative treat for their child.

The Director, in conjunction with the parents of children with peanut and tree nut allergies, will at the begin-

ning of each school year provide to all parents a letter with information about peanut and tree nut al-lergies, the BCDC policy prohibiting such foods in the Center, and a list of suggested safe lunch and snack foods for parents to send. This information will also be included in the parents’ handbook and made clear to prospective parents.

BCDC staff members and all interested parents will be trained annually and as needed (e.g., for new staff) in

how to respond in the event of accidental exposure. Where age-appropriate, BCDC children will also be educated about food allergies and the need to respect any dietary restrictions their classmates may have. Even with a peanut and tree nut-free policy in place, accidental exposure may occur, so training, preparedness and vigilance will remain essential.

Please acknowledge that you have read and understand this policy by signing below.

Parent’s Name (Print): ____________________________________ Parent’s Signature: ___________________________________________ Date: ________________

Given the increasing number of children with life-threatening allergies to peanuts and tree nuts,

we are a peanut and tree nut free Center. Below are the guidelines used for governing this policy:


Non-Prescription Medications: We encourage you to visit the Center to administer over the counter medicines. However, if this is not possible, our trained staff will administer such medications, provided you have a physician’s written authorization, the medicine is in the original bottle or package and the medicine au-thorization form is completed with the following information: your child’s name, name of medicine, doses and times the medicine should be administered, name and phone number of the child’s physician. Once all infor-mation and medicine are provided as described above, a trained staff member will administer the medication and keep a daily record of medication administered. A new prescription is needed with each illness. Sun-screen, insect repellant require a parental permission form, while diaper cream does not. An allergy action plan should be completed by a parent and physician for any child with a known allergy. A physician can write standing orders for allergy (and other regularly needed) medicine, but the parent must sign a medicine authorization form for each period of time medication is administered. The medicine authori-zation form for administering medication will not exceed ten workdays. If the parent and caregiver determine that as a result of teething your child is uncomfortable and/or presenting a low grade (under 101F) fever, your child’s physician may write a 3 month prescription for Acetaminophen (Tylenol or equivalent) that states it is to be given for symptoms relating to teething only.

* Aspirin will not be given at any time because of the danger of Reye’s syndrome. Prescription Medication: In order for our staff to administer prescr iption medications, the parent/guardian and physician must fill out a medication authorization form with the child’s name, name of medicine, doses and times medicine should be administered and then sign the form. Prescribed medication must be given to the caregiver in the original prescription bottle with the pharmacist’s label. The name on the bottle is the only person to whom we are authorized to administer the medication and then keep a daily record of the medication administered. As with non-prescription medication, we encourage you to visit the Center to administer the medicine at any time. Regarding Expiration Dates: Please note, we will not administer any medication or product past its ex-piration date. This includes, but isn’t limited to topical creams, lotions, sun screen and insect repellant.

Ravion Wynn | Assistant Director Phone: (202) 364-8799, Ext. 110 Email: [email protected]


Revised 5/17/18

In the event of inclement weather, BCDC will follow decisions made by DC Public Schools, including full closure or late opening. In addition, if DCPS closes early because of weather, BCDC will also close early, and parents should pick up their children as soon as possible.

If DCPS was previously scheduled to be closed for students (such as for a holiday, school break, parent-teacher conference day, or any other reason not related to weather), BCDC will follow the decision made for the federal government by the Office of Personnel Management (OPM).

Under unexpected or unusual circumstances, the Center director has full authority to exercise his/her judgment and open or close the center, regardless of decisions made by DCPS or OPM.

Please listen to the radio, TV, or check the DCPS and OPM websites to obtain up-to-date in-formation about DCPS and federal government closures. Center staff will also use the Tad-poles software, text or phone call to communicate with parents and teachers as early as possi-ble, and by 6 am. In addition, parents can call the BCDC Information Line at 202-364-8799, extension 4, and parents will receive an email or text from Tadpoles.

If there is an emergency at BCDC, such as a power outage or non-weather-related event, the director will make a determination as to whether to close the center to protect the health and safety of the children and staff. If the Center is closed early, all parents will be notified through Tadpoles or other means to pick up their children.

Kim Mohler | Executive Director

Phone: (202) 364-8799, Ext. 112



We are confident that BCDC families make it a priority to pick up their children on time on a daily basis. However, because we strive to provide the very best care to your children, BCDC must have a policy to discourage late pick-ups. Children often become restless and nervous when they are the last to leave for the day and when parents do not arrive on time. When parents are late, teachers and staff must work longer hours, which becomes costly due to overtime pay requirements. Teachers’ sched-ules and personal lives also are affected when late pick-ups occur. While we understand that unex-pected events happen, we hope that you will make every effort to pick up your children on time each and every day.

The following late pick-up policy was implemented on February 1, 2015. This policy will apply on a rolling, 3-month basis, beginning from the date of the first late pick up.

Families are asked to call the center prior to 6:00 p.m. whenever they are going to be late picking up. This notice allows us an opportunity to inform both your child and the teachers of when we should expect your arrival.

First late pick-up: We will give one (1) courtesy allowance.

Second late pick-up: If a parent is late a second time, your account will be billed a $50.00 late fee.

Third late pick-up: If a parent is late a third time, the Director and/or the BCDC Board has the right to request a family meeting.

If late pick-ups continue or are excessive after the third instance, the Director and/or the BCDC Board of Directors may recommend termi-nation of your enrollment at BCDC.

Please direct questions about this policy to Kim Mohler, Executive Director, either by email ([email protected]) or by phone at (202) 364-8799, Ext. 112.

Don’t Wait to Get Involved!

Become a BCDC Room Parent Today All parents traditionally devote a significant amount of time to volunteer activities at Broadcasters’ Child Development Center. They are largely responsible for BCDC governance and fundraising. Parents are also called upon to help with special projects, such as accompanying children on field trips and performing other minor tasks around the center. This volunteer involvement enhances the quality of programming for our children, and it promotes the free, open communication necessary to establish continuity between home and the Center.

One specific way to get involved is to become a Room Parent. Room Parents coordinate communications between the Director, the Board, and the families enrolled in each of our classrooms. They may help to coordinate the annual teacher appreciation lunch, help with field trips, volunteer for fundraisers, coordinate with parents to choose and purchase a teacher’s holiday gift or help with a special event.

If you’d like to become a BCDC Room Parent, please contact our Assistant Director, Ravion Wynn, either by email ([email protected]) or by phone at (202) 364-8799, ext. 110.

Thanks in advance for your involvement!

Sincerely,

The BCDC Administrative Team

Interested in being a Room

Parent?Want to know

more about what a Room Parent does?

mailto:[email protected]

Broadcasters' Child Development Center 2018 – 2019 Calendar

2018 Monday, September 3 Labor Day BCDC Closed Friday, September 7 Grandparent's Day Tea 4pm at BCDC

Wednesday, September 12 Back to School Night - Lambs, Ducklings,

Bunnies & Penguins 7pm at BCDC

Thursday, September 13 Back to School Night - Pandas, Fireflies &

Rainbow Fish 7pm at BCDC

Saturday, September 22 Book Sale 9:00am -11:00pm at Politics & Prose

Wednesday, September 26 Fall Picture Day 8:00am - 12:00pm @ BCDC Monday, October 8 Columbus Day BCDC Closed

Saturday, October 13 Fall picnic 10:00am - 1:00pm at BCDC Wednesday, October 17 BCDC Parent Meeting 6:00pm at BCDC Wednesday, October 31 Fall Festival (Halloween) Parade 4:30pm at BCDC Thursday, November 15 NAEYC Conference in DC - Staff Devel. BCDC Closed

Friday, November 16 NAEYC Conference in DC- Staff Devel. BCDC Closed Thursday, November 22 Thanksgiving BCDC Closed

Friday, November 23 Post Thanksgiving BCDC Closed Monday, December 17 Holiday Party (Tentative) 4:30pm Monday, December 24 Pre-Christmas Holiday BCDC Closed Tuesday,December 25 Christmas Holiday BCDC Closed

2019 Tuesday, January 1 New Year's Day BCDC Closed Monday, January 21 Martin Luther King Jr. Day BCDC Closed

Wednesday, February 13 BCDC Parent Meeting 6pm at BCDC Monday, February 18 President's Day BCDC Closed Saturday, February 23 Annual BCDC Fundraiser/Community Event TBD

Friday, March 1 Distribution of re-enrollment forms April 8 -12 Week of the Young Child

Wednesday, April 10 Spring Picture Day 8:00am - 12:00pm @ BCDC Friday, April 12 St. Jude Trike-a-thon 10:00 - 11:00am @ BCDC Friday, April 12 Re-enrollment forms due

May 6 - 10 Teacher Appreciation Week Friday, May 10 Teacher Appreciation Event Center closes early at 4:30 Friday, May 17 Transition Notices distributed to all families

Monday, May 27 Memorial Day BCDC Closed Friday, June 7 Achievement Picnic 4:30pm at BCDC

Thursday, July 4 Independence Day BCDC Closed Monday, August 19 through

Wednesday, August 21 Staff Development Week BCDC Closed

* BCDC anticipates the need to close for several business days to allow packing and moving when our new space is ready to be occupied. Advance notice will be given as soon as the information is available.

BCDC Parent Information Line 202-364-8799 x4

Call to hear the operating status of the Center.