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Application Enrolment Form - page 1 of 2 - Step 1 of 22

Umbrella Registration Package April 2021

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Application Enrolment Form
page 1 of 2

Please indicate which Umbrella Centre you're applying for *

Name of Child *

First

Middle

Last

Gender *

Male
Female

Child's Date of Birth *

Date of Birth

Phone *

Phone

Child's Address *

Address

City

Province

Postal Code

Country

Parent/Guardian Name *

First

Middle

Last

Address *

Address

City

Province

Postal Code

Country

Phone *

Cell Phone

Email Address *

Employer or School Name & Address *

Phone *

Parent/Guardian Name

First

Middle

Last

Address

City

Province

Postal Code

Country

Phone

Cell Phone

Employer or School Name & Address

Phone

Emergency Contact Person (Other Than Parent/Guardian)

Emergency Contact Person Name *

First

Last

Emergency Contact Person Phone Number *

Phone Number

Emergency Contact Person Cell Phone

Cell Phone

Emergency Contact Person Workplace Phone Number

Workplace Phone Number

Name of Persons to Whom Child May be Released

Person 1 to Whom Child May be Released

First

Last

Name

First

Last

Name

First

Last

Name

First

Last

Application Enrolment Form
page 2 of 2

The Child's Family Physician

Name of Child's Family Physician

Phone number of Child's Family Physician

Phone number

Address of Child's Family Physician

Address

History of Communicable Diseases

Conditions Requiring Medical Attention

Any Symptoms Indicative of Ill Health

Allergies

Any special requirements regarding diet, rest or exercise - A copy of written recommendations from child's physician, regarding specific/special needs for sleep requirements, must be provided and kept in child's file

Any special accommodations that would better assist your child in the program - i.e. as outlined in an Individualized Program Plan). If so, a copy will be kept in child's file.

School Information

Address *

Phone number

Number of Hours Child Attends School per day

Selected Value: 0

Parent/Guardian Signature *

Date *

Office Use Only

Director Signature

Date

Date of Admission

Date of Discharge

Consent Form

Emergency Medical Consent

In case of illness or accident to my child where the emergency contact or I cannot be contacted by telephone I hereby grant authority to the child care Director or designate to call an ambulance and seek any necessary medical attention.

Parent/Guardian's Signature *

Date *

Insect Repellent

Not recommended under 6 months of age, unless accompanied by a doctor's note.
For children older than 6 months, insect repellent will only be applied if provided by the parent, in original bottle and labelled with child's name.
Insect repellent will not be applied to hands or face as recommended by Health Canada.
All insect repellents provided should be 10% deet or less.

Parent/Guardian's Signature *

Date *

Sunscreen

Not recommended for children under 6 months of age unless a doctor's note is provided.
I agree to apply sunscreen to my child/children before aniving at the child care centre. I give the staff pennission to reapply sunscreen again in the afternoon before children go outside. This will ensure that children have sunscreen on at last½ hour before they are outdoors (as per guidelines set out by Public Health). We will use a waterproof 30 SPF.

Parent/Guardian's Signature *

Date *

Hand Sanitizer

Not recommended for Infants and Toddlers. The use of hand sanitizer by children will be supervised by a staff. Hand sanitizer will be provided by the Child Care program.

Parent/Guardian's Signature *

Date *

Non Medicated Diaper Cream

Non medicated diaper cream will be applied as directed by parent/guardian. Please note all prescribed creams will require a medication form to be completed.

Parent/Guardian's Signature *

Date *

All products must be provided in the original container/package labeled with the child's name. The product must be applied in accordance with any instructions on the label or by parent.

Trip Consent Form

As part of the program, the children of our centres will have opportunities to visit places of interest within the community. Many of the outings will be within walking distance and will not required transportation.

Permission *

I give my child

Child’s Name *

First

Last

permission to be taken for local walking trips. These trips are planned and supervised by the teachers in our Centre. (For example, a fall walk to note leaf colour change.)

All excursions which utilize bus transportation or which involve water will require a detailed, trip-specific form for parents/guardians to sign.

Parent/Guardian's Name *

First

Last

Parent/Guardian's Signature *

Date *

Photo Permission Form

This is a permission form allowing staff to take photographs of the children during the day. Sometimes parents request that we take pictures of their child with other children in the room during a birthday celebration or special event, etc. Please indicate below if you give permission for pictures to be taken.

Permission *

I give permission for
I do not give permission for

Child's Name *

First

Last

to have his/her photo taken.

Parent/Guardian's Signature *

Date *

Umbrella Privacy Statement

Umbrella Central Day Care Services recognizes the importance of having all personal information kept confidential. The Childcare Centres will adhere to all Federal and Provincial laws governing privacy and the guidelines set forth by the Privacy Commissioner of Canada.

Personal information given by parents/guardians will not be released to outside agencies except with consent or as required by law. These agencies are The Ministry of Community, Family, and Children’s Services and The Regional Municipality of Durham, Children’s Services Division.

Permission *

I give permission

to Umbrella Central Day Care Services Inc. to allow these Agencies to review my personal information.

Parent/Guardian's Name *

First

Last

Parent/Guardian's Signature *

Date *

Smoke Free Policy

The Smoke Free Ontario Act 2017 prohibits smoking tobacco, medical cannabis, and the use of electronic cigarettes in or on the premises and playgrounds of Umbrella Central Day Care Services. This Act prohibits smoking or holding lit tobacco in the child care and requires that Umbrella Central Day Care Services notify all employees that smoking and the use of electronic cigarettes are prohibited.

Smoking is not permitted while participating and/or volunteering on excursions. Staff, students, and volunteers as well as parents and other visitors to the centre, are advised of this non-smoking policy.

Parent/Guardian's Signature *

Date *

Parental Consent for Administration of Potassium Iodide
Consent Form

The use of KI pills is voluntary. For questions regarding thyroid blocking and potassium iodide, please contact Durham Region Health Department at (905) 723-8521.

The Provincial Nuclear Emergency Response Plan approved doses for thyroid blocking (65 mg. pills) are based on the current World Health Organization, Health Canada and Canadian Nuclear Safety Commission (CNSC) Group of Medical Advisors recommendations. They are:

 Birth through one month ¼ pill  1 month through 3 years ½ pill  3 to 12 Years 1 pill  12 to 18 Years (Less than 150 lbs.) 1 pill  12 to 18 Years (Over 150 lbs.) 2 pills  18 Years and over 2 pills

If directed by the Province of Ontario or Emergency Management Ontario,

Permission *

I GRANT permission for my child
I DO NOT GRANT permission for my child

Child's Name *

First

Last

to be administered potassium Iodide (Kl) in the prescribed dose.

Declaration

My child

Child's Name

First

Last

is allergic to Iodine.

Parent/Guardian Signature

Date

Parental Consent for Administration of Potassium Iodide

Dear Parents/Guardians:

In the event of a serious accident at either the Pickering or Darlington Nuclear Generating Station, radioactive material may escape from the Station. One type of radioactive material that may be released are radio iodines. If radioiodines are inhaled, they are absorbed by the thyroid gland. The ingestion of potassium iodide (Kl) pill will minimize the amount of radioiodine taken by the thyroid.

Programs will be advised to either shelter in place, or evacuate depending on the situation. It is expected that there will be plenty of time to close the centre and evacuate your child before radiation exposure occurs. A decision has been made to pre-distribute potassium iodide (K 1) pills to all schools and child care programs within a IO kilometre radius of the nuclear generating stations.

Durham Region Children's Services has notification procedures to alert each child care program in case of a nuclear emergency. The Provincial authorization to administer Kl and the dosage instructions will be broadcast by designated radio and television stations. We have been instructed that the issue of these pills is subject to the direction of the Province.

There may be some reaction to potassium iodide pills for individuals allergic to iodine. For this reason, it is important for parents to notify the child care centre if they know/suspect their child may have an allergic reaction. The use of potassium iodide is voluntary. Therefore, we request that you confirm your wishes regarding the administration of Kl to your child on the attached form and return it promptly to the childcare centre.

In the event that we are required to evacuate, you will be notified. If we need to evacuate with your child, Umbrella will follow direction from personnel emergency services.

Dale Kingdon, RECE
Executive Director
Umbrella Central Day Care Services

Disruption of Services

The following procedure outlines the actions that are to be taken in the event of inclement weather.

Please listen to the local radio stations for school closures and bus cancellations/delays. This information should be made available by 6:30 a.m. Find the local radio and television stations listed below.

If the announcement states that school buses are cancelled, Umbrella's programs located within the school will be open. In the event that a school is closed due to extreme weather or any other safety issue, our program will be closed and care cannot be offered.

If possible, please consider leaving work early or make arrangements for your emergency contact to pick up your child from the program. Your patience and understanding is appreciated.

Radio and television stations:

CKDO AM 1580	CBC FM 99.1	CHFI FM 98.1
BOB FM 91.9	JACK FM 92.5	CHUM FM 104.5
CBL FM 740	KX96 FM	CFRB AM
THE ROCK 94.9	Q107	CITY TV
GLOBAL TV	CFTO TV	CKDO FM 107.7

Directions to Local Emergency Evacuation Sites

Vincent Massey Before and After School Program

• Staples, 185-187 King St., Bowmanville, ON L1C 1P2

Duke of Cambridge Before and After School Program

• Staples, 185-187 King Street, Bowmanville, ON L1C 1P2

Waverley Before and After School Program

• Remedy Rx Pharmacy, 131 Waverley Rd., Bowmanville, ON L1C 3T5

S.T. Worden Before and After School Program

• McDonalds, 1300 King St. East., Oshawa, ON L1H 8J4

Bellwood Before and After School Program

• Kinder Corner, 63 Thickson Rd. S., Whitby, ON L1N 2C8

Lord Elgin Before and After School Program

• Cadarackque Public School, 15 Miles Drive, Ajax, ON L1Z 1C7

Vincent Massey – Oshawa Before and After School Program

• Edukids Child Care, 15 Harmony Road North, Oshawa, L1G 6K8

Sunset Heights Before and After School Program

• Umbrella Office, 58 Rossland Road West, Oshawa, L1G 2V5

Gandatsetiagon (Gandy) Before and After School Program, Pickering

• School House Playcare, located in Highbush Elementary School 605 Strouds Lane, Pickering ON L1V 5M5

Walter E. Harris Before and After School Program

• Hillsdale Public School, 525 Oshawa Blvd. N., Oshawa ON L1G 5T6

Queen Elizabeth School Age & Full Day Program

• Umbrella Office, 58 Rossland Road West, Oshawa, L1G 2V5

Exclusion Policy

To effectively control the spread of disease, it is the policy of Umbrella Central Day Care Services to exclude sick children, staff, volunteers and parents from the child care setting.

It is our policy that we do the following:

●	Isolate ill children until removed from the Centre by parents/guardians
●	Encourage families to have an alternate plan for childcare in the event that the Centre is unable to provide care
●	Keep ill children away from healthy children when necessary within the Centre
●	Exclude all children until they are symptom-free or as directed by the Durham Region Health Department
●	Ill parents/guardians should not be present at the Centre
●	Ill staff/volunteers should not be present at the Centre if they have been exposed to any communicable/infectious diseases or if they experience any symptoms of disease.

Compliance *

I have read and will comply with this exclusion policy

Parent/Guardian's Name *

First

Last

Parent/Guardian's Signature *

Date *

Special Needs Resourcing (SNR) Support Services

Services and agencies within Special Needs Resourcing aim to support Registered Early Childhood Educators (RECE’s) and educator teams across Durham Region in their professional practice.

The purpose of the SNR agencies in Durham is to offer resources for educators in the process of building their capacity to support all children, regardless of ability or background, within their early learning and care programs.

The goal is to ensure that educators feel supported during potential situations where additional resources and/or personnel are required.

Staff from the SNR agencies work with early learning teams, in child care settings, to support the development of individual support plans (ISP’s) and inclusive practices for children and families. If individual support plans are required to support a child, parents/guardians consent will be required.

List of all Durham Region SNR Agencies

❖	Resources for Exceptional Children and Youth (RFECY)
❖	Durham Behaviour Management Services (DBMS)
❖	Preschool Outreach Program (POP), Grandview Children’s Centre
❖	Infant and Child Development (ICD)
❖	Blind/Low Vision Team, Surrey Place Centre
❖	Region of Durham Children’s Services Division: Quality Assurance Advisors and Training Specialists

SNR PROGRAM/AGENCY	OVERVIEW OF SERVICES
Resources for Exceptional Children and Youth (RFECY)	RFECY services provide general and ongoing support to educators across a broad spectrum of topics in the form of resources, training, and hands-on coaching, with the overall goal of building capacity in professional practice. Educators will receive ongoing inclusive support in the form of onsite consultation from their Early Learning Inclusion (ELI) consultant, who can aid in initiating/supporting referrals to additional SNR agencies, ISP development, implementations of general or child specific strategies, creation and monitoring of a Collaborative Action Plan and Case Management. Support with referral for Enhanced support funding/staffing if necessary.
Preschool Outreach Program (POP), Grandview Children's Centre	POP assists in connecting the child and family to clinical assessments at Grandview to support educators in the early learning environment. The program supports educators in their inclusive practice by providing child-specific recommendations related to development in the areas of communication, fine & gross motor development, sensory processing, and daily living skills. POP does not offer general room consultations or assessments, or direct clinical therapy for a child within the child care environment.
Durham Behaviour Management Services (DBMS)	DBMS provides behaviour consultation in the form of recommendations and direct coaching for educators in early learning environments, with the goal of reducing challenging behaviours and increasing functional skills displayed by an individual child or group of children. Educators may request general behaviour support for an entire room environment, or child-specific consultations to target significant behaviour concerns.
Infant and Child Development (ICD)	ICD provides specific strategies and recommendations for educators to support the transition of a child with developmental concerns or disabilities from the home environment to the early learning setting. ICD specialists complete a full transition process with the educator team through observations, consultations, and active coaching. ICD specialists support educators in their connection with other SNR service providers for ongoing support for the child within the early learning environment.
Blind-Low Vision, Surrey Place	Blind-low vision consultants provide support to educators in the form of recommendations and strategies to ensure a child with a vision impairment has a successful transition from the home environment to the early learning setting. Consultants are able to provide potential next steps and ideas for educators to implement in support of children with either a visual diagnosis, or children who may have potential vision needs. A diagnosis is not required for general recommendations and supports related to vision concerns. A pre-referral consultation may be completed if questions arise relate to the child’s visual functioning.
Quality Assurance (QA) Advisors Training Specialists	QA advisors support early learning programs by assessing the quality of the environments and following up with potential recommendations to improve the quality of care. Yearly assessments are completed for centres with a Purchase of Service Agreement using Durham Region's Operating Criteria (DROC) tool. Where required, QA’s may refer a centre to the Training Specialist team for intensive support to meet DROC expectations.

Parent Code of Conduct

Parents, guardians, volunteers, staff and/or Board Members must be treated courteously, impartially and respectfully at all times. This applies to grounds protected by the Ontario Human Rights Code. We must treat others fairly regardless of race, creed, ethnic origin, citizenship, religion, gender, sexual orientation or disability. Adults are expected to model appropriate conduct, refraining from behaviours such as swearing, name-calling, shouting, etc. Any individuals engaging in this type of behaviour will be asked to immediately leave the premises. Failure to comply may result in police intervention.

Confidentiality must be maintained, respecting the privacy of our families, staff and volunteers; therefore, gossip within the centre and/or electronic information sharing will not be tolerated.

There will be consequences for violation of this Code of Conduct, up to and including the dismissal of the child from the Centre. Concerns and comments must be addressed initially to the Director. Should a resolution not be reached with the Director, the issue should then be brought to the attention of the Childcare Coordinator and finally, to a member of the Board of Directors.

All parties involved with your child’s attendance must sign and adhere to this Code of Conduct set forth by Umbrella Central Day Care Services Inc.

Agreement *

I have read, understand and agree with the policies and procedures outlined in the parent handbook.

Parent/Guardian Name *

First

Last

Parent/Guardian Signature *

Date *

Parent/Guardian Name

First

Last

Parent/Guardian Signature

Date

Consent to Share Information

Daily communication between professionals is an essential tool which contributes to the well-being of your child. This includes, but is not limited to developmental, behavioural, and/or academic concerns.

Shared information will remain confidential during the time your child is enrolled in our program.

By signing this release of information form you give permission for the reciprocal exchange of information between

Name of Umbrella Centre *

and

Name of Child's School *

Permission *

I give permission for

Name of Umbrella Program *

to exchange information regarding my child

Name of Child *

Parent/Guardian Name *

First

Last

Parent/Guardian Signature *

Date *

Office Use Only

Director Signature

Date

Umbrella Central Day Care Services Inc.
Personal Information Protection And
Electronic Documents Act

Effective January 1, 2004, the Personal Information Protection and Electronic Documents Act (PIPEDA) went into effect. This Act regulates Umbrella’s collection and use or disclosure of personal information in the course of our activities.

Personal information includes any factual or subjective information, recorded or not, about an identifiable individual. This includes information in any form such as a person’s e-mail address, food allergies, person’s age, home address and so on. It does not include the name, title or business address or business telephone number of an employee of an organization.

Protecting Personal Information

The Executive Director, Coordinator or Centre Director may be delegated to either act on behalf of Umbrella or to take responsibility for occasional collection, use and disclosure of personal information.

We understand the importance of protecting personal information. For that reason Umbrella has taken the following steps.

●	Paper information is either under supervision or secured in a locked or restricted area.
●	Electronic hardware is either under supervision or secured in a locked or restricted area at all times. In addition, passwords are used on computers, telephone voice mail, and cell phones.
●	Paper information is transmitted through sealed, addressed envelopes or boxes by reputable companies.

Staff are trained to collect, use, and disclose personal information only as necessary to fulfill their duties and in accordance with our privacy policy.

External consultants and agencies with access to personal information must enter into privacy (confidentiality) agreements with us.

Does Umbrella disclose personal information?

We disclose personal information

●	To institutions providing Umbrella with payroll and banking services
●	To assist with collection of outstanding child care fees
●	To our auditors, and
●	To third parties for processing of data (e.g. hardware and software support)

Unless required to do so by law, Umbrella does not currently disclose the personal information under its control to any other parties. It does not trade, sell, barter, or give away its client information to anyone. Should it be necessary in the future to make such a disclosure, Umbrella will not do so without the express consent of the individuals involved.

How do individuals provide Umbrella with their consent for the collection, use and disclosure of their personal information?

When families seek the services of Umbrella they provide their personal information expressly through a registration/referral process. Umbrella then has access only to the personal information provided by the client that is required to fulfill the purposes stated above. A client may withdraw their consent at any time upon reasonable notice, subject to legal or contractual restrictions. Please note however, that due to our statutory and regulatory obligations withdrawing consent may affect our ability to continue to provide a client with the services they have or would like to receive.

How much personal information does Umbrella collect, use or disclose?

Umbrella collects, uses and discloses the personal information it requires only in order to fulfill the purposes listed above, and no more.

Retention and destruction of personal information

Umbrella only retains personal information fot as long as is required to fulfill the purposes listed above. For example, regulations stipulate that we keep a child's file for two years after they have been discharged from a child care program. However, many of our programs retain information longer than this two year period (for example, programs where children may use the service more than once). The Canada Revenue Agency requires us to keep financial records (e.g. child care billings) for six years plus the current year.

How accurate is the personal information collected, used and disclosed by Umbrella?

Umbrella makes every effort to ensure the personal information it collects, uses and discloses is as accurate and up-to􀁋date as is required to fulfill the purposes listed above. If an individual's personal information requires amendment, they need only contact Umbrella to ensure that the correction is made.

When a file is no longer needed it is either destroyed or all personal identifiers are removed in such a way as to prevent accidenta.1 disclosure.

How secure is the personal information stored at Umbrella?

Umbrella is committed to ensuring that personal information is protected from unauthorized access, unintended disclosures or theft. This protection is provided by firewalls in the computer system, passwords to protect databases, encrypted e-mail, locked filing cabinets and limited access to certain work areas. Only the Centre Coordinator and Centre Director and delegated individuals have access to this information.

We destroy paper files that contain personal information by shredding. We destroy electronic information by deleting it, and when the hardware is discarded, we ensure that the hard drive is formatted to erase any information contained within

You can look at your information

With some exceptions you have the right to see what personal information we hold about you. Often, all you have to do is ask. Umbrella reserves the right to charge a reasonable fee for the copying of this information.

We will need to confirm your identity, if we do not know you, before providing you with access.

If there is a problem, we may ask you to put your request in writing. If we cannot give you access, we will tell you within 30 days - if at all possible - and tell you the reason, as best we can, as to why we cannot give you access.

If you believe there is a mistake in your information, you have the right to ask for it to be corrected. This applies to factual information and not to any professional opinions we may have formed. We may ask you to provide documentation that our files are incorrect. Where we agree that there is an error, we will make the correction and notify anyone to whom we sent this information. If we do not agree that there is an error, we will still be willing to include in our file a brief statement from you on the point.

Bag Lunch Policy

In programs which require children to bring a bagged lunch from home, parents are responsible for ensuring the contents are nut-safe and nutritious, following Canada’s Food Guide. Sweet snacks such as candy, cookies and sugary drinks are discouraged as they offer little nutritional value.

All bags need to be labelled with the child’s name.

If a child has allergies, religious, cultural or dietary restrictions, it is the responsibility of the parent to state nutritional requirements on enrolment forms. The Director will make the necessary arrangements regarding these restrictions.

Umbrella staff will notify parents of any other life threatening (anaphylactic) allergies, i.e. fish, eggs, and will request that the causative agents are not brought into the program.

The centre will provide morning and afternoon snacks.

Umbrella is a nut-safe organization and prohibits any foods that may contain even traces of nuts.

Parents will be notified of any life threatening (anaphylactic) allergies that are present at a specific site. Parents are responsible for ensuring that all food is safe from any other anaphylactic allergies that are specific to the site their child attends.

Soy butter, also sold as “WOW Butter” is not permitted. Although the product is actually peanut free, it creates a stressor in the classroom for the children with allergies as it looks and smells just like peanut butter.

Please sign below to show that you have read and understand this policy.

Parent/Guardian Signature *

Date *

Permission Form for Activities

Please sign below indicating that you give your child permission to participate in tattoo, face painting, henna, and nail polish activities throughout the year.

Permission *

I give permission for my child

Name of Child *

to participate in the following activities throughout the year.

Activity Participation *

Tattoo
Face painting
Henna
Nail Polish

Name of Parent/Guardian *

First

Last

Parent/Guardian Signature *

Date *

Washroom Plan

Outdoor

Before going outdoors, all children will have the opportunity to use the washroom facilities and should be encouraged to do so. If during outdoor time, children need to use the washroom, they will be accompanied inside by a teacher. If there is only one teacher, the whole group will have to go inside. Children will not be allowed in the school from outdoors unsupervised unless they are going directly to another staff inside who has been notified that they are coming. (i.e. outdoor teacher uses walkie-talkie and notifies indoor teacher that the child is coming to use the washroom. Kindergarten children will always be accompanied by a teacher.

Indoor

Upon arrival to the school age program, a group washroom routine should be conducted where each child has the opportunity to use the washroom. During program time, school age children can be sent by themselves, or with a buddy depending on their age. Whenever possible, a visual check should be made by the staff in the direction of the school age washroom. The kindergarten children will only use the washroom in the kindergarten classroom. If a washroom is not available in the classroom, the kindergarten children must be accompanied by a staff. If there is only one staff in the program the whole group must go accompanied by the teacher.

Suspension of Services

In the event that a child has been suspended from school, Umbrella Central Day Care Services will not be able to offer care for your child until their school suspension is over. The Durham District School Board and the Kawartha Pine Ridge School Board have a policy in place stating that if a child is suspended he or she is not allowed on school property. Umbrella will not allow your child to attend our programs since we are located on school property and we support the Board of Education policies. There will be no fee charged for the days your child is unable to attend our program.

Termination Policy

Umbrella Central Day Care Services will make every effort to service all children and their families enrolled in our program. Parents must read and sign the “Parent Code of Conduct” prior to their child starting at the centre.

Umbrella’s Parent Code of Conduct reads:

“Parents, guardians, volunteers, staff and/or Board Members must be treated courteously, impartially, and respectfully at all times. This applies to grounds protected by the Ontario Human Rights Code. We must treat others fairly regardless of race, creed, ethnic origin, citizenship, religion, gender, sexual orientation or disability. Adults are expected to model appropriate conduct, refraining from behaviours such as swearing, name-calling, shouting, etc. Any individuals engaging in this type of behaviour will be asked to immediately leave the premises. Failure to comply may result in police intervention.

There will be consequences for violation of this Code of Conduct, up to and including the dismissal of the child from the centre. Concerns and comments must be addressed initially to the Director. Should a resolution not be reached with the Director, the issue should then be brought to the attention of the Childcare Coordinator and finally, to a member of the Board of Directors.

All parties involved with your child’s attendance must sign and adhere to this Code of Conduct set forth by Umbrella Central Day Care Services Inc.

There may be situations in which the program cannot meet the needs of the child and/or their family. In this case the Directors, Coordinators, and Board of Directors have the right to determine that a child should be withdrawn. The decision will be decided in the best interest of the child with consideration of the safety and well-being of the children and staff. If at any time the safety or well-being of the staff or child is threatened, the Director reserves the right to terminate care immediately. The decision for termination will be based on, but not limited to the following types of incidents;

●	Extreme physical acts against other children and/or staff
●	Verbal attacks on other children and/or staff, which include the use of threats, name calling, bullying, etc.
●	Verbal or physical abuse by a child.

At the onset of problems, the child’s behaviour will be recorded and documented by staff and the Director. Included will be any precipitating incidents. A meeting will be arranged with parents, staff and the Director. Meetings will be scheduled when not disruptive to the program.

If the incident concerns a school age child, an Incident Report Form will be completed by the staff in the classroom. The Incident Report outlines the following: what happened/causes/what led up to the incident and strategies. This form is signed by the teacher, directors and child. The form also asks if this is the first incident and if not, staff are to record the incident number.

Should the parent and staff determine that the child may require additional services, provided by outside agencies, such as Behaviour Management, Resources for Exceptional Children and Youth, etc., the staff will connect the family with the proper services for their child. The Director and staff will reference “No Wrong Door” for direction.

Compliance *

I have read and will comply with this Termination Policy.

Parent/Guardian Signature *

Date *

Office Use Only

Witness Signature

Date

Client/Parents Travel Declaration

In accordance with Umbrella Central Day Care Services’ Pandemic Policy, all families/clients are required to sign the following declaration form in the event of a pandemic event. The purpose of the travel declaration is to ensure the health and safety of the staff and families/clients of our organization. We will only request that you sign the travel declaration in the event that the Public Health Agency of Canada, Ontario Ministry of Health, and/or the Regional Public Health/Medical Officer of Health require that individuals self-isolate who have travelled or have been exposed locally to a virus. Viruses can spread easily from person to person.

Declaration *

I declare that I and/or no member of my immediate family, who reside with me, have not travelled to any areas deemed a health risk or travel advisory by the Canadian Government in the last 14 days.

Declaration *

declare that I have not been visited in my home by anyone who has visited any areas deemed a health risk or travel advisory within the last 14 days.

Declaration

I declare that I have travelled to

Name of Place

within the last 14 days. I agree to abide by the stipulations outlined by the the Public Health Agency of Canada, Ontario Ministry of Health, and the Regional Public Health/Medical Officer of Health and my child(ren) not return to the program until at least 14 days after travel.

Declaration

I declare that I have family members in my home who have been in

Name of Place

within the last 14 days. I agree to abide by the following stipulations , i.e. self-isolation, quarantine as outlined by the the Public Health Agency of Canada, Ontario Ministry of Health, and the Regional Public Health/Medical Officer of Health and my child(ren) will not return to the program until at least 14 days after the family member returns from travel.

Name *

First

Last

Signature *

Date *

Ill Health Form - For Office Use Only

Ill Health Form For: ___________________________________________
DATE	ILL HEALTH (IDENTIFY SYMPTOMS/ACTION TAKEN)

Parent Orientation Checklist - Office Use Only

In Children's File:

Application/Enrolment Form (2 pages)	□
Consent Form	□
Trip Consent Form	□
Photo Permission Form	□
Privacy Statement	□
Smoke Free Policy	□
Potassium Iodide Consent Form/Letter	□
Bad Weather Closures/ Disruption of Services (programs in schools)	□
Emergency Evacuation Information	□
Exclusion Policy	□
Ill Health Form	□
Special Needs Resourcing (SNR) Support Services	□
Parent Code of Conduct/Signature Page	□
Consent to Share Information Form	□
Personal Information and Electronics Documents Act (3 pages)	□
Bag Lunch Policy (programs in schools)	□
Permission Form for Activities	□
Washroom Plan	□
Suspension of Services	□
Termination Policy	□
Client/Parents Travel Declaration	□
Fee Schedule	□
Parent Handbook Agreement Form	□

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