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J U S T “ P l a i n s ” K I D S JUST “Plain’’ FUN Cindee Rosevear Licensed Child Care since 1979 (303)622-9785 Fax (3

J U S T “ P l a i n s ” K I D S JUST “Plain’’ FUN Cindee Rosevear Licensed Child Care since 1979 (303)622-9785 Fax (303)622-9784 License # 49007. BUSINESS HOURS: This day care home is open Monday through Friday from 6:00 a.m. to 6:00 p.m.

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J U S T “ P l a i n s ” K I D S JUST “Plain’’ FUN Cindee Rosevear Licensed Child Care since 1979 (303)622-9785 Fax (3

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  1. JUST “Plains” KIDSJUST “Plain’’ FUNCindee Rosevear Licensed Child Care since 1979(303)622-9785 Fax (303)622-9784 License # 49007 • BUSINESS HOURS: This day care home is open Monday through Friday from 6:00 a.m. to 6:00 p.m. • Children not picked up by 6:00 p.m. will be charged $1.00 per minute. No charges will be assessed when lateness is due to weather or a serious emergency situation. • OPEN DOOR POLICY: This day care home has an “open door policy” which means that parents may come into the home to drop off or pick up your children during business hours without knocking or ringing the doorbell. Due to recent events in the world the front door will remain locked for security reasons. • HOLIDAYS: This day care home will be closed on New years eve day closing early at 1:00 p.m.,New Years Day, Memorial Day, July 4th, Labor Day, Thanksgiving Day and the following Friday , closing early at 1:00 p.m. on Christmas Eve Day and closed Christmas Day. • MEALS: This day care home is a member of the U.S.D.A.. Food program. The U.S.D.A. monitors the foods served to your child/children insuring the nutritional value meets the standards set by the U.S.D.A.. Meals including Breakfast, Mid-morning snack, Lunch, Afternoon snack and Dinner when necessary are provided free of charge. BREAKFAST is served from 6:00 a.m. to 7:30 a.m. If your children will need Breakfast, please have them arrive before 7:30 a.m. • PRESCHOOL: Preschool is included for all children ages 2-5 years at an additional charge $25.00 per month. Some field trips may require additional funds . The preschool schedule follows the Strasburg school calendar.

  2. VACATION PERSONAL DAYS: There is no charge for your family vacation, up to 2 weeks per year, provided it is taken in at least one week blocks and notification is given in advance. I will have 1 week ofPAID vacation and 1 week of non-paid vacation per year. Substitute child care will supplied if possible. Substitute care for personal appointments, sickness will be provided. Sick days for children are NOT discounted. • THIS DAY CARE HOME DOES NOT DISCRIMINATE BECAUSE OF RACE, COLOR, CREED OR DISABILITIES. • AJUSTMENT PERIOD: All children will be taken on a trial basic for two weeks for parents and children to become familiar with the provider and programs. Anytime during this period the parent or the provider may terminate the contract if either parent or provider feel that it would be in the best interest of the child. • CLOTHING: Please bring your child dressed, including shoes, coat if necessary (clean diaper if applicable). Please leave a clean, complete change of clothing (including under garments) in case it may be needed. Children using diapers must provide the diapers. Children in potty training may need to leave several changes of clothing. • TOYS AND BLANKETS: To avoid loss or breakage of a favorite toy, please leave toys at home. If toys are brought the children will be responsible for them, not I. Exceptions are a favorite blanket or soft toy for nap time. Objects may be brought for show and tell in preschool. • MEDICATIONS POLICY: Prescriptive and non prescriptive medication for eyes, ears, all oral medication, medication for burns, all topical medications, and individual special medical procedures can ONLY be provided on written order from Physician (medical permission form) as well as written permission from parent (parental medical permission form).

  3. All medication must be kept in the original container. Prescription medicine container must bear the original pharmacy label that shows the prescription number, name of medication, date filled, physicians name, physicians phone number child’s name and dosage and method of administering the medication. • When no longer needed the medication must be returned to the parents or destroyed. • Medications must be dispensed and a record made (medication log form). Medications must be dispensed by a person trained in first aid and medication administration. • INTAKE AND AUTHORIZATION FORMS:All forms including, intake information, child’s medical record, over the counter drugs permission, permission for medication and emergency information and authorization forms MUST be returned before your child will be admitted. • COMMUNICATION: Please feel that you can speak with me any time if you have concerns about your child. Call me during the day or make an appointment to have a conference with me. I believe that communication between the parents and myself is the best way to insure quality care for your child. • RATES AND FEE POLICY: A one time fee of $35 will be made at the time of enrollment. • One child under one year $160 • One child (over one and through potty training) $150.00 • One child potty trained to kindergarten $145 • Two children (over two years and potty trained) $240.00 • Two children (one under two, one over two) $250.00 • School age children (summer, holiday, breaks) $135 • Before and After school (includes Breakfast and afternoon snack) $75.00 (includes school holidays, sick • All school age children will be charged full day rates during Christmas break, Spring break and summer vacation. • Drop in or daily rate : $40 per day • ALL FEES ARE PAYABLE ONE WEEK IN ADVANCE, unless other arrangements have been agreed upon.

  4. ADDITIONAL AUTHORIZATION • PERMISSION FOR FIELD TRIPS • I/We give permission for my/our child to go on trips away from the premises of the child care home, in the company of Cindee Rosevear or other agreed upon responsible adults, whether on foot or by vehicle. • SIGNATURE OF PARENT/GUARDIAN______________________________________DATE________________ • SIGNATURE OF PARENT/GUARDIAN__________________________________________________ DATE___________________ • ********************************************************************************************* • PERMISSION TO VIEW VIDEOS/TELEVISION • This day care home allows children to watch children’s programs from television, satellite, or videos. No programming will be viewed that is rated anything but G. • Children in this day care home will not watch television/video for more than one hour at a time or three hours per day (at the most). • SIGNATURE OF PARENT/GUARDIAN__________________________________________________DATE____________________ • SIGNATURE OF PARENT/GUARDIAN__________________________________________________DATE___________________ • ************************************************************************************************************** • PERMISSION FOR TRANSPORTATION • I give permission for Cindee Rosevear to transport my child to and from activities. It is understood that if the outing is by car a child restrain seat is mandatory for those children required by Colorado State Law. All children and the driver must wear a seat belt. • SIGNATURE OF PARENT/GUARDIAN__________________________________________________DATE___________________ • SIGNATURE OF PARENT/GUARDIAN__________________________________________________DATE___________________ • ************************************************************************************************************* • SWORN AND SUBSCRIBED BEFORE ME THIS__________DAY OF 20________. • MY COMMISSION EXPIRES:_______________________________________________ • NOTARY PUBLIC_______________________________________________________

  5. NO REFUNDS OR CREDITS WILL BE GIVEN FOR MISSED DAYS. HOLIDAYS ARE NOT DISCOUNTED. • THERE WILL BE A $20.00 CHARGE FOR RETURNED CHECKS. THIS FEE IS PAYABLE BEFORE THE CHILD RETURNS. • SECURITIES POLICY: Parents: Your child/children will not be released to anyone who is not listed on your intake form. If you wish to add or remove names at anytime please ask me for the form and update it. If you are unable to pick up your children and unable to have anyone listed on the release form pick up the children, you must call me in advance and advise me. I will then ask you to add that person to the list when you return. If school age children are in care and you want me to pick them up at school due to illness or cancellation, I MUST BE LISTED ON THE SCHOOL RELEASE FORM. • I must be notified if there is a divorce or change in custody while the child/children is in my care. I am obligated by LAW to release the child/children to either parent unless I have a legal order in my possession stating otherwise • No child will be released to a parent or authorized person who is intoxicated. I will ask that someone else be called to pick up the child/children. If refused I will call the police or other child protection services. • QUESTIONS OR CONCERNS ABOUT MY LICENSE: Call Adams County Department of Social Services at (303) 421-8121 or call The State of Colorado Department of Child Care Services at 1-800-799-5876 or write: 1575 Sherman Street, Denver CO 80203-1714. • If you suspect child abuse or neglect you may contact the above numbers. If I suspect child abuse or neglect I will contact the appropriate authorities.

  6. DISCIPLINE POLICY: All children are expected to behave in an age appropriate socially acceptable manner. • There will be NO biting, scratching, swearing, bullying, pushing, back talking or other offensive behavior in day care. • All children try most of the above at some point and will be disciplined in the following manner: • 1. The behavior will be brought to the child’s attention and the child will be asked to discontinue. • 2. If the behavior does continue a time- out of 5 minutes will be given after the child is reminded of the behavior in question. • 3. Repeat 2, increase time-out to 10 minutes. • 4. Parents will be informed and ask to help with a remedy. • 5. The provider will decide if the child will continue in day care after a consultation with parents. • NOTE: NO CHILD WILL BE VERBALLY HUMILIATED OR PHYSICALLY ABUSED, per common sense and the LAW. • DISASTER PLAN: In the unlikely event of a disaster I would have a plan in place for: • FIRE: This house is equipped with smoke detectors and fire extinguishers on each floor. There is an escape route from the front door as well as the patio door and the garage The downstairs has a permanent escape ladder to the window and an escape ladder from the window well . The children and I practice fire drills, announced and unannounced. • FLOOD: We don’t live in a flood district but in case of a real unlikely situation, I would bring all of the children to the highest point and call 911 for a rescue. • TORNADO: We practice tornado drills regularly. We would all go to the basement bathroom or store room under the stairs as advised by the Strasburg Fire Dept. because those rooms have no windows. • ADDITIONAL: In the event of any disaster, my first concern would be the safety of the children. After I am sure they are protected, to the best of my ability, I would make every attempt to notify the parents of their safety either by phone or emergency personal. My house is equipped with a battery operated TV , cell phone, and radio. • I have read and understand this contract: • Parent/Guardian signature____________________________________date____________________ • Parent.Guardian signature____________________________________date____________________ • Provider signature__________________________________________date_____________________

  7. OVER THE COUNTER MEDICATIONS • As a licensed day care provider, I am unable to dispense any medication to your children unless prescribed in writing by your physician. This includes ALL over the counter drugs such as cough syrup, pain medication or topical ointments. Please have your physician complete this list and return it to me with physician’s signature, parents signature, and notarized. • ACETAMINOPHEN: yes/no_____dosage_________method_____________Brand____________________ • COUGH SYRUP: yes/no_____dosage_________method_____________Brand____________________ • DECONGESTANT: yes/no_____dosage_________method_____________Brand____________________ • EXPECTORANT: yes/no_____dosage_________method_____________Brand____________________ • COLD SYRUP: yes/no_____dosage_________method_____________Brand____________________ • IBUPROPHEN: yes/no_____dosage_________method_____________Brand____________________ • OTHER MEDICATIONS • ______________: yes/no_____dosage_________method_____________Brand____________________ • ______________: yes/no_____dosage_________method_____________Brand____________________ • ______________: yes/no_____dosage_________method_____________Brand____________________ • ______________: yes/no_____dosage_________method_____________Brand____________________ • Physicians signature:___________________________________________date________________ • Parent’s signature:_____________________________________________date________________(Notary on parents signature only) • SWORN AND SUBSCRIBED BEFORE ME ON THIS __________DAY OF 20____. • MY COMMISSION EXPIRES :_____________NOTARY PUBLIC_______________________________

  8. PERMISSION FOR MEDICATION • NAME OF CHILD_______________________________________________AGE______________ • CHILDCARE FACILITY: Just “Plains” Kids, Cynthia Rosevear, owner, teacher, provider. • PRIMARY HEALTH CARE PROVIDER_______________________________________________ • MEDICATION:______________________DOSAGE___________________ROUTE____________ • PURPOSE OF MEDICATION:_______________________________________________________ • TIME OF DAY MEDICATION IS TO BE GIVEN________________________________________ • POSSIBLE SIDE EFFECTS:__________________________________________________________ • ANTICIPATED NUMBER OF DAYS IT NEEDS TO BE GIVEN AT CHILD CARE FACILITY _____________. • date________ Signature of Person with Prescriptive Authority_____________________________ • ******************************************************************************* • PARENT/GUARDIAN • I hereby give my permission for _____________________________________________________ to take the above prescription or over- the- counter medication at the child care facility as ordered. I understand that it is my responsibility to furnish this medication. • DATE________________Signature of Parent/Guardian___________________________________ • NOTE: The prescription medication is to be brought to the Child Care facility in it original pharmacy container appropriately labeled by the pharmacy or person with prescriptive authority along with a copy of the medication authorization order.

  9. CHILD’S MEDICAL RECORD(To be taken to child’s doctor for his/her signature) • Dear Doctor: • __________________________________is to be cared for in my licensed Day Care Home. State regulations require that a signed statement be obtained from a doctor annually certifying that each child has no illness or communicable disease. Please complete the form below and list any information of which you feel I should be aware. • DAYCARE PARENT________________________________________________________________________ • ADDRESS ________________________________________________________________________ • NAME OF CHILD________________________________________DATE OF BIRTH___________________ • Is this child free of contagious disease?:___________________________________________________________ • General condition of health?:___________________________________________________________________ • Allergies?:__________________________________________________________________________________ • Drug reactions?:______________________________________________________________________________ • Surgeries?___________________________________________________________________________________ • IMMUNIZATIONS: Attach forms from Dr. complete with date of shots. • GROUP NUMBER:_______________________________________________________ • SUSCRIBERS NUMBER:__________________________________________________ • SIGNATURE OF BOTH PARENTS: __________________________________________DATE________________ • __________________________________________ DATE________________ • DOCTORS SIGNATURE____________________________________________________DATE________________ • DOCTORS ADDRESS_________________________________________PHONE NUMBER___________________

  10. CHILDS INTAKE • DATE______________ • PARENTS SIGNATURE__________________________________________________________ • PARENTS SIGNATURE___________________________________________________________ • Child’s name______________________________Name used______________________________ • Address__________________________________________________Phone__________________ • Sex_________Birth date____________Admission date_________________________ • Father’s name__________________________________Occupation_________________________ • Business address_____________________________________Business phone_________________ • Mother’s name__________________________________Occupation_________________________ • Business address_____________________________________Business phone_________________ • If parents cannot be reached: emergency numbers: • Name______________________________________Address_______________________________ • Phone______________________Relationship___________________________________________ • PERSONS AUTHORIZED TO PICK UP CHILD: • Name___________________________________________________________________________ • Name___________________________________________________________________________ Name___________________________________________________________________________ • Serious illness or accidents to date:___________________________________________________ • Allergies___________________________________Particular habits(eating, sleeping, playing, etc..) • ________________________________________________________________________________ • What types of control over child’s behavior are most frequently used?________________________ • ONLY TIME-OUT WILL BE USED FOR DISCIPLINE! • OTHER CHILDREN IN FAMILY?______Names_______________________________Birth date_______ • Names______________________________ Birth date________ • Names_______________________________Birth date_______ • Names______________________________ Birth date________

  11. EMERGENCY INFORMATION AND AUTHORIZATION: 3 COPIES • CHILDS NAME________________________________________________ • ADDRESS____________________________________________________ • CITY_______________________________________ZIP_______________ • BIRTH DATE______________ (attach picture here) • HOME PHONE______________________________ • MOTHERS NAME______________________________ FATHERS NAME_______________________ • ADDRESS_____________________________________________ ADDRESS___________________________________ • CITY_________________________________________________ CITY________________________________________ • EMPLOYER, address______________________________ EMPLOYER, address________________________________ • WORK PHONE #_______________________________________ WORK PHONE # ____________________________ • SSI #_________________________________________________ SSI #________________________________________ • EMERGENCY CONTACTS OTHER THAN PARENTS: • NAME___________________________________________________PHONE #___________________________________ • NAME___________________________________________________PHONE #___________________________________ • DOCTOR_________________________________________________PHONE #___________________________________ • DENTIST________________________________________________ PHONE #___________________________________ • HOSPITAL_______________________________________________ PHONE #___________________________________ • MEDICAL PLAN__________________________________________POLICY #___________________________________ • ALLERGIES_________________________________________________________________________________________ • ADVERSE REACTIONS TO DRUGS_____________________________________________________________________ • We hereby give my/our permission to Cindee Rosevear or a DESIGNATED SUBSTITUTE to obtain Emergency Medical or Surgical Care for My/Our child__________________________________________should the need arise. • I/We understand that a conscientious effort will be make to locate Me/Us before emergency action is taken. Whether or not My/Our prior consent is obtained, the expenses of emergency medical treatment or care will be assumed by Me/Us. • In cases where (911) Emergency Crews respond, I/We give permission to those responding to use their skill and training to do whatever is necessary to save the life of My/Our child. I/We agree to be responsible for these expenses including transportation to the hospital by ambulance (air life) if this should be necessary. • SIGNED___________________________________________DATE_________________________ • SIGNED___________________________________________DATE_________________________ • SWORN AND SUBSCRIBED BEFORE ME THIS ___________DAY OF 20________________. • MY COMMISSION EXPIRES:_____________________NOTARY PUBLIC_______________________________________________ • CITY________________________________________ CITY_______________________

  12. DAILY LOG OF MEDICATION ADMINISTEREDUSE ONE SHEET FOR EACH CHILD • NAME_____________________BIRTH DATE_____________JUST “Plains” KIDS • START DATE________20______END DATE_________20____________LENGTH OF TIME MEDICATION IS TO BE GIVEN________________ • PHONE_______________________PERSON WITH PERSCRIPTIVE AUTHORITY___________________________________________ • MEDICATION_______________________DOSAGE_________ROUTE_________________ADMINISTRATION TIMES________________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • DATE__________TIME____________COMMENT_____________________________________________________INITIAL__________ • SIGNATURE______________________________________________________INITIALS__________DATE___________ • DIRECTIONS: PERSON ADMINISTERING SPECIALIZED MEDICATION SHALL INITIAL IN SPACE DAILY AND INCLUDE IDENTIFIYING SIGNATURE AT THE BOTTOM OF THE PAGE ONLY ONE TIME. • IF CHILD IS ABSENT OR IF FOR ANY REASON THE MEDICATION IS NOT GIVEN, INDICATE IN “COMMENT” COLUMN. • ADDITIONAL COMMENTS SHOULD BE ENTERED ON THE BACK OF THE SHEET

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