Commencement

These Regulations shall come into force on the 1st day of December, 1998. MADE by the Minister of Human Development, Women and Youth this 9th day of November, 1998. (DOLORES BALDERAMOS GARCIA) Minister of Human Development, Women and Youth 38 Social Service Agencies SCHEDULE (Regulation 4(1)(a)) FORM I APPLICATION FOR A DAY CARE LICENCE FOR ALL NEW FACILITIES Date ____________________ Non-refundable application fee: $25.00 Name of Applicant: ______________ Telephone number: ___________ Name of prospective operator if different from name of applicant: ___________________________________________________________ Mailing or home address: ______________________________________ Address of the day care facility (if any): ___________________________ Telephone number at the day care facility: _________________________ Type of Facility: Category 1 _____ Category 2 _____ Category 3 _____ (✓ as appropriate) Category 1 – separate building Category 2 – separate section of building Category 3 – services within the regular family setting Have you ever applied or held a day care facility licence before? _____ Yes _____No (✓ as appropriate) If yes, for what reasons are you reapplying? ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Social Service Agencies 39 Please complete the following information for the services you intend to provide: _____ I will be the operator and the provider at the day care facility. _____ I will be the operator of the day care facility and employ providers (✓ as appropriate) Capacity (number of children) ________ Ages of the children: ________ Staff/providers (number and names): ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Commencement date of proposed operation _____ Hours of operation: ___________________________________________________________ Day care yearly calendar: ______________________________________ ___________________________________________________________ Services offered: _____________________________________________ ___________________________________________________________ Proposed fees: _______________________________________________ ___________________________________________________________ Other: ______________________________________________________ I have received a copy of: The Operational Manual for Day Care Providers _____ Yes _____ No The Social Services Agencies (Operators of Day Care Facilities) (Registration, Licensing and Minimum Operating Requirements) Regulations. _____Yes _____ No. (✓ as appropriate) 40 Social Service Agencies I understand that an interview/inspection is part of the application/reapplication process. I hereby give consent to allow access to the Registrar or his authorized representative to the day care facility and records. I understand that any false statements contained herein will make me subject to certain penalties as set out in the Regulations. I understand that notification of any changes regarding location, operator, services, capacity, or providers must be immediately reported to the Registrar and to the Ministry. ___________________ ____________________ Applicant’s Signature Date Licence #: ____________________ FOR OFFICIAL USE ONLY: __________ Fees collected _____________________ Date of inspection Interview and inspection _______________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Enclosures: letters of reference _____ medical ______ Criminal Record check _____ DCF policies _____ Social Service Agencies 41 FORM II (Regulation 4(1)(b)) APPLICATION FOR A TEMPORARY LICENCE FOR EXISTING DAY CARE FACILITIES Date ____________________ Non-refundable application fee: $25.00 Name of Applicant: ______________ Telephone number: ___________ Name of prospective operator if different from name of applicant: ___________________________________________________________ Mailing or home address: ______________________________________ Address of the day care facility: ____________________________ Telephone number at the day care facility: _________________________ Type of Facility: Category 1 _____ Category 2 _____ Category 3 _____ (✓ as appropriate) Category 1 – separate building Category 2 – separate section of building Category 3 – services within the regular family setting How many years have you been in operation? __________ Please complete the following information: _____ I will be the operator and the provider at the day care facility. _____ I will be the operator of the day care facility and employ providers (✓ as appropriate) 42 Social Service Agencies Capacity (number of children) ________ Ages of the children: ________ Staff/providers (number and names): ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Hours of operation: ___________________________________________ ___________________________________________________________ Day care yearly calendar: ______________________________________ ___________________________________________________________ Services offered: _____________________________________________ ___________________________________________________________ Fees: ______________________________________________________ Other: ______________________________________________________ I have received a copy of: The Operational Manual for Day Care Providers _____ Yes _____ No The Social Services Agencies (Operators of Day Care Facilities) (Registration, Licensing and Minimum Operating Requirements) Regulations. _____Yes _____ No. (✓ as appropriate) I understand that an interview/inspection is part of the application process. I hereby consent to allow access to the Registrar or his authorized representative of the Ministry to the day care facility and records. I understand that any false statements contained herein will make me subject to certain penalties as set out in the Social Services Agencies (Operators of Day Care Facilities) (Registration, Licensing and Minimum Operating Requirements) Regulations. Social Service Agencies 43 I understand that this is an application for a temporary licence and that I have a grace period of three years to meet the minimum requirements set out in the Social Services Agencies (Operators of Day Care Facilities) (Registration, Licensing and Minimum Operating Requirements) Regulations. I understand that notification of any changes regarding location, operator, services, capacity, or providers must be immediately reported to the Registrar and to the Ministry. ___________________ ____________________ Applicant’s Signature Date Licence #: ____________________ FOR OFFICIAL USE ONLY: __________ Fees collected _____________________ Date of inspection Interview and inspection _______________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Enclosures: letters of reference _____ medical ______ Criminal Record check _____ DCF policies _____ 44 Social Service Agencies FORM III (Regulation 4(1)(c)) RENEWAL APPLICATION FOR A DAY CARE LICENCE Date ____________________ Fee for renewal of licence: $15.00 Name of Operator: ______________ Telephone number: ___________ Mailing or home address: ______________________________________ Name and address of the day care facility: _________________________ ___________________________________________________________ Telephone number of day care facility: ___________________________ Current licence number: _______________________________________ Date issued: ________________ Expiry Date: ________________ Do you wish any changes to be made to the conditions in your licence? _____ Yes _____ No (✓ as appropriate) Please indicate any proposed changes below: ___________________________________________________________ Operator: ____________________ Provider(s): ____________________ ___________________________________________________________ Location/address: ____________________________________________ Name of the day care facility: ___________________________________ Services offered: _____________________________________________ Social Service Agencies 45 Type of licence: ______________ Category of facility (1,2,3): ________ I understand that an inspection is a part of the renewal process. ___________________ ____________________ Operator’s Signature Date 46 Social Service Agencies FORM IV (Regulation 6(5)) NOTIFICATION OF INTENTION To: ______________________________ Date: _______________ (Name of Operator on Licence) Please take notice that pursuant to the powers vested in me under the Social Service Agencies Act, Chapter 45, and the Regulations made thereunder, I hereby give you notice that I intend to ____________________ Refuse to issue a licence to you ____________________ Refuse to renew your licence ____________________ Suspend your licence ____________________ Cancel your licence ____________________ Restore your licence to operate a day care facility at __________________________________ ___________________________________________________________ For the following reasons: ___________________________________________________________ ___________________________________________________________ And further take notice that under section 22 of the said Act, you have the right to appeal this matter to the Minister within 14 days of this notice. ___________________ ____________________ Signature of the Registrar/ or Date authorized representative Social Service Agencies 47 FORM V (Regulation 17(2)(a)) STATEMENT OF HEALTH OF CHILD TO BE ENROLLED I, ___________________________________________, have examined (Physician/Public Health Nurse name) _____________________________________ and have determined that (Child’s name) he/she (circle one) is in good physical and mental health to attend and participate at __________________________________ day care facility. Immunizations are up to date: _____ Yes _____ No (✓ as appropriate) Immunizations needed: ________________________________________ ___________________________________________________________ ___________________________________________________________ Special health conditions, allergies, problems: ______________________ ___________________________________________________________ ___________________________________________________________ History of contagious disease: ___________________________________ ___________________________________________________________ ___________________________________________________________ __________________________________ ____________________ Physician/Public Health Nurse Signature Date 48 Social Service Agencies FORM VI (Regulation 17(3)) STATEMENT OF HEALTH OF PROVIDER/ASSISTANT/STAFF MEMBER I, ___________________________________________, have examined (Physician/Public Health Nurse name) _____________________________________ and have determined that (Name of provider, assistant or staff member) he/she (circle one) is in good physical and mental health to care for young children at __________________________________. (Day Care Facility name) Immunizations are up to date: _____ Yes _____ No (✓ as appropriate) Immunizations needed: ________________________________________ Special considerations: ________________________________________ ___________________________________________________________ ___________________________________________________________ __________________________________ ____________________ Physician/Public Health Nurse Signature Date Social Service Agencies 49 FORM VII (Regulation 17(2)(b)) DAY CARE FACILITY CHILD ENROLMENT FORM Date: __________ Name of Date Care Facility: _________________ Child’s name: ____________________________ Age: _____ Sex: _____ Child’s Address: _____________________________________________ Child’s date of birth: _____________ Date of enrolment: _____________ PARENTAL INFORMATION Mother’s Name: __________________ Telephone Number: __________ Mother’s address (home): ______________________________________ Mother’s address (work): _______________________________________ Mother’s work telephone number: _______________________________ Father’s Name: __________________ Telephone Number: __________ Father’s address (home): _______________________________________ Father’s address (work): _______________________________________ Father’s work telephone number: ________________________________ Name of child’s doctor/clinic: ____________ Telephone number: ______ Doctor’s Address: ____________________________________________ 50 Social Service Agencies In case of emergency, please contact: Name: _______________________ Telephone number: ______________ Address: ____________________________________________________ Relationship to child: __________________________________________ Are there special considerations, health problems, or allergies that influence the child’s participation in the day care program? ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ __________________________, wish to enrol _____________________ (Parent’s name) (Child’s name) in the day care program for the following schedule: (Please check the following) ____ Monday ____ Tuesday ____ Wednesday ____Thursday ___ Friday Hours: ____ Monday ____ Tuesday ____ Wednesday ____Thursday ___ Friday ___________________ ____________________ Parent’s Signature Date Social Service Agencies 51 FORM VIII (Regulation 17(2)(c)) AUTHORIZATION FORM FOR ADMINISTERING MEDICATION I, ________________________________________________, authorize (Parent’s name) _____________________________ of ____________________________ (Provider’s name) (Name of Day Care Facility) to administer _____________________________________.to my child (Name of Medication) the following conditions _______________________________________ ___________________________________________________________ _____ times a day, for _____ days, every _____ hours. I understand that the medication must be labelled clearly with my child’s name, instructions for use and, if by prescription, the nurse/doctor’s signature. __________________________________ ____________________ (Parent’s signature) Date 52 Social Service Agencies FORM IX (Regulation 17(2)(d)) AUTHORIZATION FORM FOR ADMINISTERING MEDICATION I, ________________________________________________, authorize (Parent’s name) _____________________________ of ____________________________ (Provider’s name) (Name of Day Care Facility) to administer emergency healthcare to my child in the case of an injury/accident/sickness. This includes transporting my child to ____________________________________ hospital for immediate (Name of child’s doctor/hospital/clinic) medical attention if the situation calls for such action and that I be notified as quickly as possible. __________________________________ ____________________ (Parent’s signature) Date Social Service Agencies 53 FORM X (Regulation 17(2)(e)) AUTHORIZATION TO DROP OFF/ PICK UP CHILD The following individuals are authorized to drop off and pick up my child at the day care facility. I agree that these persons must present proper identification for the release of my child into their care. 1. Name: __________________________ Telephone: _____________ Address: ________________________________________________ Relationship to child: ______________________________________ Signature: _______________________________________________ 2. Name: __________________________ Telephone: _____________ Address: ________________________________________________ Relationship to child: ______________________________________ Signature: _______________________________________________ 3. Name: __________________________ Telephone: _____________ Address: ________________________________________________ Relationship to child: ______________________________________ Signature: _______________________________________________ __________________________________ ____________________ (Parent’s signature) Date 54 Social Service Agencies FORM XI (Regulation 17(2)(f)) FIELD TRIP PERMISSION FORM I, _________________ give permission for my child, ________________ (Name of Parent) (Child’s name) to be taken on a field trip to ____________________________________ (Destination) on ________________________________, leaving the day care facility at __________ am/pm and returning to the day care facility at __________ am/pm. I give permission for my child to be transported in a _____ car _____ bus _____ boat. (✓ as appropriate) I understand that each child must have an individual permission form, even if they are member of the same family. __________________________________ ____________________ (Parent’s signature) Date