Forms and Resources

Registration Form

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- Step 1 of 4

Child’s Information

Full Name *

Nickname

Date of Birth *

Place Of Birth *

Sex *

Male
Female

Home Street Address *

City *

Zip *

Parent/Guardian’s Information

Mother/Guardian’s Name

SS#

Home Street Address

City

Zip

Home Telephone

Cell/Beeper

Company Name

Work Telephone

Address

Address Line 1

City

State

Zip Code

Address Relationship Name

Father/Guardian’s Name

SS#

Home Street Address

City

Zip

Home Telephone

Cell/Beeper

Company Name

Work Telephone

Address

Address Line 1

City

State

Zip Code

Sibling(s)

Name(s)

Age(s)

Child’s Pediatrician

Phone

Address

Address Line 1

City

State

Zip Code

Allergies

Medical Problems

Emergency Contacts and others authorized to pick-up child if parent is unavailable

Contact/Pick-up Name

Telephone

Address

Relationship

Contact/Pick-up Name *

Telephone *

Address

Relationship

Contact/Pick-up Name

Phone

Address

Relationship

I understand that for registration to be valid I must present upon enrollment

Complete all informational forms.
Present the following documentation from the child’s physician or health provider:
- Proof and results of the child’s recent physical exam (no more than 1 year old from date of first class).
- Health history.
- Proof of the immunization as required by the New Jersey State Dept. of Health.

I understand that my child cannot attend The Magic Garden School until the immunizations are up to date.

Printed Name

Date

CONTRACT FORM

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- Step 1 of 10

Mother/Guardian’s Name *

SS# *

Home Street Address *

City *

Zip *

Home Telephone *

Cell Or Work Telephone *

Length Of Time At Current Address

Father/Guardian’s Name *

SS# *

Home Street Address *

City *

Zip *

Home Telephone *

Cell Or Work Telephone

Length Of Time At Current Address

Work Checkboxes week

Child’s Name

Age

Nickname

Date

Sex

Male
Female

First Day At School

Is There A Court Order Limiting Access? If Yes, Attach A Copy Of The Court Order And Complete A & B.

A. Name Of Person Under Court Order With Limited Access

B. Please Provide Any Information You Feel Is Pertinent.

This Agreement Is Between (print) And The MAGIC GARDEN SCHOOL.

1- BASIC SERVICES

My child will be in the (circle one) Infant Toddler Nursery Pre-School Before / After Summer class.

The center shall provide the following basic services for childcare excluding days the center is closed (check choices):

Checkboxes

Full day, full week, M-F program between

Time

and

Time

Full day, partial week program between

Full day, partial week program between

Time

and

Time

Half day program between

Half day program between

Time

and

Time

Days per week on

Pre-K program between 9 A.M. and 11:30 A.M. for

Pre-K program between 9 A.M. and 11:30 A.M. for days per week on as prearranged

days per week on as prearranged

Checkboxes

Before school, between

Time

and

Time

days per week on

Checkboxes

After school, between

Time

and

Time

days per week on

Checkboxes

Summer Camp, between

Time

and

Time

days per week on

2-REGISTRATION

Parent agrees to pay the following at registration:

Tuition for the first week of attendance ...... $

Deposit (equal to tuition choice) ...... $

Registration Fee (Non Refundable) ...... $

Multiple Child Discount, if applicable ...... $

Amount Paid: ...... $

Balance Due before child starts at the center: ...... $

3- TUITION

Parent agrees to pay the following regular tuition:

Tuition per week ...... $

Sheet and blanket supply ...... $

Multiple Child Discount, if applicable

Tuition:

4- LATE PICK-UP FEES & SERVICE FEES

Late pick-up fee is $5.00 for each minute the child remains after 6:00 P.M.
Service fees: the center shall charge for returned check for non-payment (NSF) $65.00 per check. After 2 returned
checks, cash or money order will be required for payment.

5- COLLECTION FEES

I agree that if my account is referred to an outside agency or attorney for collection, I will be responsible for an additional
Collection Fee of $50 or 20% of the balance owed, whichever amount is greater.

6- HOLIDAY, VACATION AND ILLNESS

I am obligated to pay my child’s tuition even if my child is absent due to vacation, illness or school closings.

7- PAYMENT POLICY

Payments are due either (a) weekly on Friday prior to the week of service if this is a weekly contract or (b) on the last day of the
month, if this is a monthly contract. Payment received after the due date will be charged a late fee of $20.00 per week. If payment
is not made in full within 5 business days of the due date, the center may terminate service until payment is made. Deposits will
be applied to the last week (month) of service. If two weeks notice is not given I forfeit the security deposit.

8-SIGNATURE TO AGREEMENT

I agree to cooperate with the general policies of the center, to perform the obligation of parents or guardians set forth in this
agreement, and to abide by the rules, regulations, and manuals promulgated and provided by the center. My signature below
indicates that I have read the terms of this agreement and the rules, regulation, and manuals promulgated and provided by the
center. It further indicates that I have had this material explained to me and that all my questions have been answered.

Director Parent/Guardian Parent/Guardian

Date

A. BASIC SERVICE

The child shall be placed in a group of peers based on age and/or special needs as determined by the center.
The child shall be involved in a program of play and learning experiences that are appropriate for the ages of children enrolled in the center. A balance of active and quiet play is provided for, with individual and group activities geared toward the emotional, social, physical, aesthetic, and individual growth of young children.
The child shall be administered physician-prescribed and non-prescription medication upon the written request of the child's parents or guardians. The center shall have no responsibility of any kind whatsoever for failure to provide requested Prescription medication nor for any adverse reaction caused by the administration of such medication.
The child shall be provided with an opportunity to nap between 12:30 P.M. and 2:30 P.M. on a cot or mat provided by the center.
The center shall give appropriate first aid to hurt children. A parent or guardian shall be contacted if it is the judgment of the staff that immediate medical attention is necessary. If it is the judgment of the staff that the injury is of an emergency nature, paramedics shall be called by the center and a parent/guardian shall be contacted.
An ill child shall be isolated and given appropriate care until called for by a parent or guardian or designated Representative.
The center shall notify the child's parents or guardians of a suspected exposure to communicable disease.
The center shall make every effort to safeguard personal belongings brought by the child, but shall not be responsible for lost or broken items.
The director or any other staff members shall report to children's protective service, police department or DYFS as provided by state law of suspicion of child
abuse, sexual or otherwise, neglect, or endangerment of which they may become aware.
The child shall be given assistance with personal care as needed.

B. ILLNESS POLICY

It is the policy of the Magic Garden School that any child who has the following illness or symptoms will not be admitted to the school on a given day, unless medical diagnosis from a licensed physician has been received by us in writing, stating that the Child poses no serious health risk to him/herself or to the other children. Such illness or symptoms of illnesses shall include, but not be limited to:
- Severe pain or discomfort
- Unusual behavior (irritability or lethargy)
- Acute diarrhea. Vomiting
- Fever over 100 degrees Fahrenheit
- Severe coughing
- Sore throat
- Yellow eyes or jaundiced skin
- Red or pink eyes with discharge
- Infected, untreated skin patches
- Difficult or rapid breathing
- Weeping or bleeding skin lesions that have no
- Being treated by a physician
- Swollen joints
- Visibly enlarged lymph nodes
- Stiff neck
- Blood in urine/bowel movement
If your child has any of the above symptoms, he/she may not return to school until they are symptom free for 24 hours.
Your child may return to school once he/she is symptom free for 24 hours or a licensed physician indicates that the child poses no serious risk to him/herself or to other children.
If a child has already been admitted to school and manifests any of the above illnesses or symptoms, the child will be removed from the group and placed in a separate room or area.
Any parent/guardian or emergency contact notified of a sick child must arrange pick-up within one hour. There will be NO EXCEPTIONS.

C. HOURS OF OPERATION and HOLIDAYS

The Magic Garden School is open from 6:45 A.M. to 6:00 P.M., Monday through Friday, twelve months of the year. The center is closed on the following days, plus others to be announced:
- New Year's Day
- Good Friday
- Memorial Day
- Fourth of July
- Labor Day
- Thanksgiving and the day after
  Christmas Day
- 1 Service/Training day per year

D. PAYMENT PROVISION

Nonrefundable registration fee shall be paid upon enrollment.
Payment is due on either (a) Friday for the following week if this is a week-to-week contract or (b) the last day of the prior month if a monthly contract
Refunds of unused tuition and fees shall be given upon two weeks notice of withdrawal from the program.
No credit shall be given for days the enter is officially closed.

E. OBLIGATIONS OF PARENTS OR GUARDIANS

A parent or guardian shall furnish requested medical information not more than ten days after enrollment.
A parent, guardian, or designated representative of the child's parent or guardians shall sign the child out on the
appropriate register before taking the child from the Premises.
A parent/guardian shall notify the center when someone other than those named on the emergency information card will be calling for the child.
The parents or guardians shall provide the child with two small sheets and a blanket or other covering to use during nap period if the child stays at school after 12:30 P.M. or be charged a fee for their provision.
The parents or guardians shall see that the child is dressed appropriately when brought to the center.
The parents or guardians shall notify the center of the child's possible exposure to a communicable disease.
The parents or guardians shall notify the center when the child is absent.
The parents or guardians shall give two weeks notice or forfeit two week's tuition and fees, in case of withdrawal from program.
The parents or guardians shall abide by the parking rules of the center.
The parents or the guardians shall notify the center when the child will not be called for at the time specified when signing in.
The parents or the guardians shall respect the nonreligious nature of our programs.
The parents or guardians shall refrain form reprimanding children of other families while on the premises.
The parents or guardians shall come to the center for a conference when asked to do so by a member of the center's Staff.

F. TERMINATION OF THE AGREEMENT

This agreement shall be terminated if any one or more of the following occur:

Serious illness of the child, preventing attendance,
Failure of the parents or guardians to honor the obligations listed in this agreement or any rules, regulations, or manuals promulgated or provided by the center,
If the parents or guardians of the child allow their account to become delinquent, and for non payment,
The center in its sole and unfettered discretion determines that it is unable to meet the needs of the child,
The center in its sole and unfettered discretion determines that it is not in the best interest of the program or other children enrolled at the center to have the child in attendance,
Failure of the child's parents or guardians to cooperate with the center which the center in its sole and unfettered discretion is serious enough to warrant termination,
Disruptive or dangerous behavior of children,
Abuse of other children, staff, or property by parents or guardians

UNIVERSAL CHILD HEALTH RECORD

Endorsed by: American Academy of Pediatrics, New Jersey Chapter
New Jersey Academy of Family Physicians

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- Step 1 of 4

SECTION I - TO BE COMPLETED BY PARENT(S)

Child’s Name *

First

Last

Gender *

Male
Female

Date of Birth *

Does Child Have Health Insurance? *

If Yes, Name of Child's Health Insurance Carrier *

Parent/Guardian Name *

Home Telephone Number *

Work Telephone/Cell Phone Number *

I give my consent for my child’s Health Care Provider and Child Care Provider/School Nurse to discuss the information on this form.

Date *

This form may be released to WIC. *

SECTION II - TO BE COMPLETED BY HEALTH CARE PROVIDER

Date of Physical Examination:

Results of physical examination normal?

Abnormalities Noted:

Weight (must be taken within 30 days for WIC)

Height (must be taken within 30 days for WIC)

Head Circumference (if <2 Years)

Blood Pressure (if >3 Years)

IMMUNIZATIONS

Immunizations

Immunization Record Attached
Date Next Immunization Due:

Date:

Date Next Immunization Due:

MEDICAL CONDITIONS

Chronic Medical Conditions/Related Surgeries

• List medical conditions/ongoing surgical concerns:

Please selecet

None
Special Care Plan Attached

Comments

Medications/Treatments

• List medications/treatments:

Please selecet

None
Special Care Plan Attached

Comments

Limitations to Physical Activity

• List limitations/special considerations:

Please selecet

None
Special Care Plan Attached

Comments

Special Equipment Needs

• List items necessary for daily activities

Please selecet

None
Special Care Plan Attached

Comments

Allergies/Sensitivities

• List allergies:

Please selecet

None
Special Care Plan Attached

Comments

Special Diet/Vitamin & Mineral Supplements

• List dietary specifications:

Please selecet

None
Special Care Plan Attached

Comments

Behavioral Issues/Mental Health Diagnosis

• List behavioral/mental health issues/concerns:

Please selecet

None
Special Care Plan Attached

Comments

Emergency Plans

• List emergency plan that might be needed and the sign/symptoms to watch for:

Please selecet

None
Special Care Plan Attached

Comments

PREVENTIVE HEALTH SCREENINGS

Hgb/Hct

Date Performed

Record Value

Lead

Capillary
Venous

Date Performed

Record Value

TB (mm of Induration)

Date Performed

Record Value

Other:

Date Performed

Record Value

Other:

Date Performed

Record Value

Hearing

Date Performed

Record Value

Vision

Date Performed

Record Value

Dental

Date Performed

Record Value

Development

Date Performed

Record Value

Scoliosis

Date Performed

Record Value

Checkboxes

I have examined the above student and reviewed his/her health history. It is my opinion that he/she is medically cleared to participate fully in all child care/school activities, including physical education and competitive contact sports, unless noted above.

Name of Health Care Provider (Print)

Date

Section 1 - Parent

Please have the parent/guardian complete the top section and sign the consent for the child care provider/school nurse to discuss any information on this form with the health care provider.

The WIC box needs to be checked only if this form is being sent to the WIC office. WIC is a supplemental nutrition program for Women, Infants and Children that provides nutritious foods, nutrition counseling, health care referrals and breast feeding support to income eligible families. For more information about WIC in your area call 1-800-328-3838.

Repeater Layout Number

Section 2 - Health Care Provider

Please enter the date of the physical exam that is being used to complete the form. Note significant abnormalities especially if the child needs treatment for that abnormality (e.g. creams for eczema; asthma medications for wheezing, etc.).
- Weight – Please note pounds vs. kilograms. If the form is being used for WIC, the weight must have been taken within the last 30 days.
- Height – Please note inches vs. centimeters. If the form is being used for WIC, the height must have been taken within the last 30 days.
- Head Circumference – Only enter if the child is less than 2 years old.
- Blood Pressure – Only enter if the child is 3 years or older.
Immunization – A copy of an immunization record may be copied and attached. If you need a blank form on which to enter the immunization dates, you can request a supply of Personal Immunization Record (IMM-9) cards from the New Jersey Department of Health, Vaccine Preventable Diseases Program at 609-826-4860. The immunization record must be attached for the form to be valid.
- “Date next immunization is due” is optional but helps child care providers to assure that children in their care are up to date with immunizations.
Medical Conditions – Please list any ongoing medical conditions that might impact the child's health and well-being in the child care or school setting.
1. Note any significant medical conditions or major surgical history.
  If the child has a complex medical condition, a special care plan should be completed and attached for any of the medical issue blocks that follow.
  A generic care plan (CH-15) can be downloaded at www.nj.gov/health/forms/ch-15.dot or PDF. Hard copies of the CH-15 can be requested from the Division of Family Health Services at 609-292-5666.
2. Medications – List any ongoing medications. Include any medications given at home if they might impact the child's health while in child care (seizure, cardiac, or asthma medications, etc.). Short-term medications such as antibiotics do not need to be listed on this form. Long-term antibiotics such as those for urinary tract infections or sickle cell prophylaxis should be included.
  PRN medications (as-needed medications) should have guidelines for when administration is appropriate. Please be specific about any over-the-counter (OTC) medications you recommend, and include information for the parent and child care provider about dosage, route, frequency, and possible side effects. Many child care providers may require separate permission slips for prescription and OTC medications.
3. Limitations to Physical Activity – Please be as specific as possible and include dates of limitation as appropriate. Any limitation to field trips should be noted. Note any special considerations such as avoiding sun exposure or allergens. Potential severe reactions to insect stings should be noted. Special considerations such as back-only sleeping for infants should be noted.
4. Special Equipment – Enter if the child wears glasses, orthodontic devices, orthotics, or other special equipment. Children with complex equipment needs should have a care plan.
5. Allergies/Sensitivities – Children with life-threatening allergies should have a special care plan. Severe allergic reactions to animals or foods (wheezing, etc.) should be noted. Pediatric asthma action plans can be obtained from The Pediatric Asthma Coalition of New Jersey at www.pacnj.org or by phone at 908-687-9340.
6. Special Diets – Any special diet and/or supplements that are medically indicated should be included. Exclusive breastfeeding should be noted.
7. Behavioral/Mental Health Issues – Please note any significant behavioral problems or mental health diagnoses such as autism, breath-holding, or ADHD.
8. Emergency Plans – May require a special care plan if interventions are complex. Be specific about signs and symptoms to watch for. Use simple language and avoid the use of complex medical terms.
Screening – This section is required for school, WIC, Head Start, child care settings, and some other programs. This section can provide valuable data for public health personnel to track children's health. Please enter the date that the test was performed. Note if the test was abnormal or place an "N" if it was normal.
- For lead screening, state if the blood sample was capillary or venous and include the test result value.
- For PPD, enter millimeters of induration, and the date listed should be the date read. If a chest x-ray was done, record the results.
- Scoliosis screenings are done biennially in the public schools beginning at age 10.
This form may be used for clearance for sports or physical education. As such, please check the box above the signature line and make any appropriate notations in the Limitation to Physical Activities block.
Please sign and date the form with the date the form was completed (note the date of the exam, if different).
- Print the health care provider's name.
- Stamp with the health care site's name, address, and phone number.