Judah Ministries Enrollment Packet - Judah Ministries Inc

The following items are required for application processing no less than 5 days prior to start date. Incomplete applications will not be processed.

• $100.00 Non- refundable technician fee per applicant
• Birth Certificate
• Applicant's SSN
• Physician's Physical (no later than 30 days old)
• Most recent immunization records
• Food and Medical Allergies
• Feeding Plan (infants only)signed by doctor
• Medication for medical needs/ food allergies
• Special Dietary Needs
• Medical Consent form
• Emergency Preparedness Plan
• Parents notice
• Special Needs (first steps for ages 2 & under)

• Disciplinary Model Policy
• Field Trip Permission
• Parent Handbook
• Safe Transportation
• Safe Conditions
• Serious Illness
• Transportation Policy
• KRI Permission Slip
• Home Language Survey
• CACFP Application
• Liability Waiver
• Dietary Needs
• Special Education

OR other during

Location Preference

Pride Academy West 1
5615 W. 22nd Street
Indianapolis, IN 46224
317.247.1553

Pride Academy West 2
5570 Crawfordsville Road
Speedway, IN 46224

Pride Academy North 1
5711 N. Michigan Road
Indianapolis, IN 46228
317.672.9200

Pride Academy North 2
7601 N. Michigan Road
Indianapolis, IN 46268
463-221-2902

Parents Responsibility

Mission Statement

Application information must be kept current. If there are any changes it is the parent / Guardians responsibility to notify Pride Academy immediately. The Physician Healthcare form must be signed and dated by the physician, updated annually or when a child receives new vaccinations.

We believe every child deserves a successful childhood. Poverty, neglect, abuse, violence, separation from parents and learning disabilities greatly inhibit the potential of the child to become a happy, successful and contributing citizen in America. Through our program, Pride Academy, in partners􀄿ip with the family, enables children to reach their potential. For more than twenty years, Pride Academy has been a leader in providing a full range of services for children who are desperately in need.

Trial Phase

Prohibited on Premises

All new clients will be placed in the care of Pride Academy for a two-week trial phase. This trial period allows students, parents and staff to familiarize themselves with new faces, become acquainted with new personalities, and adjust to the new routines, procedures and Prides mission. In the course of this two-week time frame each party has the right to terminate, at will, this agreement.

Pride Academy does not allow tobacco smoking, alcohol consumption, illegal drug use, and paraphernalia substances on its premises. The use of any Contraband and Illegitimate products are prohibited when transporting children in vehicles to and from our activity. All restrictions are firmly enforced. Violation of this ordinance will result in a loss of child care with Pride Academy.

Office of Early Childhood & Out of School Learning

Local Child Care Resource and Referral Services Provider

Child Care Answers (SDA 3)

https://childcareanswers.com

Telephone: 317-636-5727

Toll Free: 800-272-2937

General info from OECOSL
Coach and training changes
OMWPK & I-LEAD Indiana Learning Paths
I-LEAD/Indiana Learning Paths
Access I-LEAD/Indiana Learning Paths
SPARK Learning Lab
Brighter Futures Indiana

https://www.in.gov/fssa/2552.htm
https://www.in.gov/fssa/coretinder/5713.htm
https://www.in.gov/fssa/coretinder/4932.htm
800-299-1627
https://secure.in.gov/app/fssa/childcare/portal/home
https://indianaspark.com
800-299-1627

Immunization Schedule - Center for Disease Control

Vaccine

DTop/DTP/TD
OPV/IPV(Polio)
MMR
HIB
Hepatitis B
Hepatitis A
Voricella
Pneumococcal (PCV)

Required Shots

5
4
2
3
3
2
1
4

Dosage 1

2 Months
4 Months
15 Months
2 Months
Birth
12 Months
15 Months
2 Months

Dosage 2

4 Months
4 Months
6 Years
4 Months
2 Months
18 Months

4 Months

Dosage 3

6 Months
18 Months

6 Months
18 Months

6 Months

Dosage 4

18 Months
6 Years

18 Months

Dosage 5

6 Years

Pride Academy - Academic and Extra Curriculum Activities

Kindergarten Preparedness
Weekly Academic Curriculum
Boy Scouts

Violin Lessons
STEM Scouts
Girl Scouts

Pertonnance Arts & Theatre
Gardening Curriculum
Career Choices

Spanish Curriculum
Young Bankers Club
Summer Camp

Weekly Childcare Rates

Age Group

Infant
1 Year Old
2 Year Old
3 Year Old
4-5 Year Old
School Age
School Age (All Dav)
On Mv Wav Pre-K

West 1 PTQ4

$435.00
$374.00
$374.00
$295.00
$295.00
$155.00
$278.00
$324.72

West 2 PTQ4

$435.00
$374.00
$374.00
$295.00
$295.00
$155.00
$278.00
$324.72

North PTQ4

$435.00
$374.00
$374.00
$295.00
$295.00
$155.00
$278.00
$324.72

Allegiant PTQ3

$229.00
$120.00
$216.00

Pride Academy - Open/Close Timeframes & Weekly Transportation fee

Location

West 1 & West 2
North 1 & North 2
OMWPK

Operation Hours Monday -Friday

6:00am - 5:00pm
6:30am - 5:00pm
8:00am - 5:00pm

Transportation Weekly Rate

$20.00 - One-Way
$30.00 - Two-Way

REGISTRATION APPLICATION

Name *

Date of Birth

Sex

Male
Female

Ethnicity

Medical Conditions/Allergies/Special Needs

_________________________________________________________________________________________________

Name

First

Middle

Last

Date of Birth

Sex

Male
Female

Ethnicity

Medical Conditions/Allergies/Special Needs

_________________________________________________________________________________________________

Name

First

Middle

Last

Date of Birth

Sex

Male
Female

Ethnicity

Medical Conditions/Allergies/Special Needs

_________________________________________________________________________________________________

Name

First

Middle

Last

Date of Birth

Sex

Male
Female

Ethnicity

Medical Conditions/Allergies/Special Needs

*********************************************************************************************************

MOTHER OR GUARDIAN INFORMATION

Name

First

Last

Relationship

Address (Fill In Below)

Address Line 1

City

State

Zip Code

Phone

Phone Type

Home
Cellular

Email

MOTHER OR GUARDIAN EMPLOYMENT INFORMATION

Employer

Employer Address

Address Line 1

City

State

Zip Code

Phone

Extension

****************************************************************************************************

FATHER OR GUARDIAN INFORMATION

Name

First

Last

Relationship

Address

Address Line 1

City

State

Zip Code

FATHER OR GUARDIAN EMPLOYMENT INFORMATION

Employer

Employer Address

Address Line 1

City

State

Zip Code

Phone

Extension

**********************************************************************************************************

CHILD'S PHYSICIAN INFORMATION

Physician's Name

Phone

Address

Address Line 1

City

State

Zip Code

CHILD HEALTH lNFORMATION RECORD

PER CHILD

Name *

Birth Date

Sex

Male
Female

Address

Address Line 1

City

State

Zip Code

Phone

Phone Type

Cell
Home
Office

Physician's Name: *

Physician's Phone:

Medical History: ( Examples: Allergies, Diabetes Asthma, ADHD, Bee Stings, Seizures, etc.)

Current Medications: (list all medications dosages and times)

Emergency Contacts:

Parent's Name *

Phone

Parent's Name

Phone

If there are areas of concern, please explain:

Name *

Phone

Relationship to child

Name *

Phone

Relationship to child

Consent for Medical Treatment of a Minor Child

Child's Name *

Birth Date

Child's Name

Birth Date

Child's Name

Birth Date

I, *

Birth Date

the parent/guardian of the above listed child(ren) here by authorize adult employees (over age 18) of Judah Ministries Inc/Pride Academy to provide transportation. and consent to necessary medical treatment for my minor child{ren). The consent is not limited but may include authorization: for certified medical personal to perform examinations, health treatment, and physical diagnosis, administer anesthetic, execute surgery, or any medical treatment and/or hospital care to be rendered to the above minor children. Medical consent must be given under the general supervision and/or advice of any physician or surgeon licensed to practice medicine in the state of Indiana in the case that I cannot be contacted.

This authorization of consent Is valid for limited ten (10) year period.

From Date

To Date

Signature of Parent/Guardian: *

Date

Preschool Age Information Sheet

PER CHILD

Age Group

2 (Year Old)
3 (Year Old)
4 (Year Old)
5 (Year Old)

Child's Name *

Nick Name

Address

Address Line 1

City

State

Zip Code

Phone

Birth Date

Age

Parents/Guardian Name: *

Siblings Name and Age:

Pets Type and Name:

Left/Right Handed (Choose One)

Left Handed
Right Handed

Favorite Toys, Books, Songs, or Games:

Please tell us about the things your child enjoys doing:

Does your child play well with the other children?

Yes
No

Does your child have opportunities to play with other children?

Yes
No

Check all that applies to your child

in diapers
toilet trained
in the process of being trained
needs bathroom assistance

What would you like to see your child learn/ do during this school year?

Additional information that will help us to know your child better:

School Age Information Sheet

PER CHILD

Child's Name *

Nick Name *

School

Address

Address Line 1

City

State

Zip Code

Phone

Birth Date

Age

Parents/Guardian Name: *

Siblings Name:

Age

Siblings Name:

Age

Siblings Name:

Age

Pets Type and Name:

What are your favorite school subjects?

What are your hobbies?

Name three things that interest you most?

Transportation Policy

Reason this policy is important:

The safety of children and staff must be provided in all activities of child care programs. Proper restraint systems and the correct use of them are critically important during travel to/from the child care program as well as a part of the activities of the setting.

Procedure and Practices, including responsible person(s):

• Consent for Child Care Program Activities form will be filled out for each child being transported.
• Smoking is prohibited in vehicles used to transport children.
• Children will be transported properly in a seat belt, car seat, or booster seat according to current Indiana regulations. Parents may be required to supply a booster or car seat as needed for their child if field trips involving use of transportation are a part of the program. Staff will be sure that car seats, booster seats and seat belts are used properly and each child is properly secured before setting the vehicle in motion. Staff will assist with releasing children from their transportation safety restraints, when needed. All adults in the vehicle will use proper restraining devices according to the vehicle manufacturer's recommendations.
• The number of passengers in the vehicle will not exceed the manufacturer's stated capacity for the vehicle.
• Children will be prohibited from eating, drinking, standing, or other dangerous or distractive activities during transportation.
• Children will never be left unattended in a vehicle, even for brief periods. All children will be accompanied by an adult to/from the vehicle to assure safety.
• All children will be accounted for before leaving the facility and again before returning.
• Children with special needs will h9ve their transportation plans addressed in the Special Care Plan. A staff member who is familiar with the chile's special needs will accompany the child during transportation.
• All travel routes will be planned in advance.

Vehicle Requirements

• Only insured, licensed, well-maintained vehicles will be used to transport children. 18 passenger vans are not permitted.
• Aback up vehicle will be available if needed and can be dispatched immediately in case of an emergency.
• A first aid kit and list of emergency contacts for all children and adults will be in the vehicle during transportation of children.
• A cell phone will be available in case of emergency.

Driver Qualifications

• Drivers will be Legally-licensed and shall not be under the influence of any chemical substance that may alter their ability to drive safely.
• Drivers will meet staff qualifications. Including a criminal- history check
• Drivers will be first aid and CPR certified if another staff member present is not.
• Drivers will obey all traffic regulations
• The driver shall not be included in the child: staff ratio. Drivers must not be distracted from safe driving practices by being simultaneously responsible for the supervision of children.
• The driver will be· familiar with the planned route ahead of time.
• Drivers will have evidence of a safe driving record for the previous 5 years.
• To prevent distractions, the driver is not permitted to talk on a cell phone or play loud music.

Alisia Jackson, Executive Director is responsible for collecting background checks, driving histories and updating this information yearly for those who are transporting children.
Alisia Jackson, Executive Director 1s responsible _ for ensuring the safety of the vehicle and proof of insurance for the vehicle.

When the policy applies:

This policy is in force anytime children are transported by the child care program. Staff will adhere to the policy guidelines even if no children are present when using a vehicle owned by the child care facility.

Communication plan for staff and parents:

Office/staff personnel will cover policies, plans, and procedures with all new staff (paid and volunteer) during orientation training. They will sign that they have read, understand and .agree to abide by the content of the policies.
• During enrollment this policy will be reviewed by Office/staff personnel with the parents. Parents will sign that they have read, understand, and agree to abide by the content of the policies.
• A copy of all policies will be available during all hours of operation to staff and parents in the policy handbook.
• Parents may receive _a copy of the policy upon request. A summary of mis policy will be included in the parent handbook.
• Parents and staff will receive written notification of any updates. • Parents will sign consent for Child Care Program Activities fonn for all outings where transportation is required.

References:

• Indiana Bureau of Motor Vehicles: www.in.gov/bmv or 317-233-6000
• National Highway Traffic Safety Administration: www.nhtsa.dot.gov or 888-327-4236
• Caring for Our Children: http://nrc.uchsc.edu
• Model Child Care Health Policies - http://www.scels-healthychildcarepa.org

Reviewed By:

Name *

Date

Director/Owner

Name

Date

Health Professional

Name

Date

Parent, advisory committee, police, Child Protective Service}

Effective Date and Review Date:

This policy is effective on the date below (choose today's date)

and will be reviewed annually by Judah Ministries Inc.
Parents and staff will be notified of any upcoming policy review

Today's Date

Home Language Survey

The purpose of this survey is to determine the primary or home language of the student. The Home Language Survey (HLS) must be given to all students enrolled at Pride Academy. The HLS is administered to dete􀀊e whether or not the student will qualify for additional English language development support (through the current school district). Please note the answers provided below are student-specific.

Please answer the following questions regarding the language spoken by the student:

IN what country was your child born?

What is the native language of the child?

What language(s) does the child speak at home?

What language( s) do the parents/ guardians use most when speaking to the child?

Student Name

First

Last

Birthdate

Parent/Guardian Name

First

Last

Consent for the use of ISTAR-KR

By: Pride Academy 5616 (Name of Agency) | School Number: E118

I,

hereby consent to my child's participation in the ISTAR-KR (Indiana Standards Tool for Alternate Reporting of Kindergarten Readine􀃋s) assessment Use of the ISTAR-KR assessment will allow me to receive periodic reports ou the skills 1/hat my child has demonstrated in tl1e areas that build toward kindergarten readiness and eventual success in school.

I understand that any data obtained from my child's ISTAR-Iffi assessment will be stored in a secure database that is maintained by the Indiana Department of Education and also designed to be compliant With the Family Educational Rights and P1ivacy Act (34 CFRfart 99).

I understand that my chilc!l's ISTAR-KR data may be· accessed only by the program/facilizy or local education agency in which 111Y child currently is enrolled. I further understand that my child's ISTAR-KR data will be made available to any Indiana-public school that my child may attend in the future.

I understand that granting consent for the use'· of the ISTAR-I{R assessment is voluntary. I also understand that I may revoke my consent at any time but that such revocation must be in writing in order to become effective. I further understand tbat any revocation of consent shall not be retroactive and, therefore, will not apply( to IS'i'.AR-KR assessments conducted prior to the written revocation of consent

Student Full Legal Name

First

Last

Student's Date of Birth

Parent/Guardian Legal Name

First

Last

Relationship to Student

Parent/Guardian Legal Name

First

Last

Date

ITEMS NEEDED - INFANTS

All items entering the facility cannot be open...
MUST be brand new in original store packaging.
Unopened items include:

• 2 Baby Bottles
• Baby Pacifier
• 4 Extra Clothing (Pants. shirts, socks)
• Diapers
• Wipes
• FAMILY PICTURE

ITEMS NEEDED - PRESCHOOL

• Blanket
• 4 Extra Clothing (Pants. shirts, socks)
• FAMILY PICTURE

Location Preference

Parents Responsibility

Mission Statement

Trial Phase

Prohibited on Premises

Office of Early Childhood & Out of School Learning

Local Child Care Resource and Referral Services Provider

Immunization Schedule - Center for Disease Control

Pride Academy - Academic and Extra Curriculum Activities

Weekly Childcare Rates

Pride Academy - Open/Close Timeframes & Weekly Transportation fee

REGISTRATION APPLICATION

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

*********************************************************************************************************

MOTHER OR GUARDIAN INFORMATION

MOTHER OR GUARDIAN EMPLOYMENT INFORMATION

****************************************************************************************************

FATHER OR GUARDIAN INFORMATION

FATHER OR GUARDIAN EMPLOYMENT INFORMATION

**********************************************************************************************************

CHILD'S PHYSICIAN INFORMATION

CHILD HEALTH lNFORMATION RECORD

PER CHILD

Emergency Contacts:

If there are areas of concern, please explain:

Consent for Medical Treatment of a Minor Child

This authorization of consent Is valid for limited ten (10) year period.

Preschool Age Information Sheet

PER CHILD

School Age Information Sheet

PER CHILD

Transportation Policy

Reason this policy is important:

Procedure and Practices, including responsible person(s):

Vehicle Requirements

Driver Qualifications

When the policy applies:

Communication plan for staff and parents:

References:

Reviewed By:

Director/Owner

Health Professional

Parent, advisory committee, police, Child Protective Service}

Effective Date and Review Date:

Home Language Survey

Please answer the following questions regarding the language spoken by the student:

Consent for the use of ISTAR-KR

ITEMS NEEDED - INFANTS

ITEMS NEEDED - PRESCHOOL

HELLO USER