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Hubbliville Academy

Enrollment Package 1.0

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SIMS Enrollment Package

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Parent/Guardian Information
Parent/Guardian 1 Name*
Relationship to child*
Phone*
Email*
Parent/Guardian 2 Name
Relationship to child
Phone
Email
Child's Information
Child's Name*
Preferred Name / Nickname*
Date of Birth*
Date Format: MM slash DD slash YYYY
Sex*
- Male
- Female
Child's Primary Language*
Language primarily spoken at home*
Start day*
Date Format: MM slash DD slash YYYY
Applying for which program?*
- Toddlers (15 months - 2.9 yrs)
- Preschoolers (2.9 - 5 yrs)
Please choose 5 Day Schedule:*
- 8:30 AM-5:30 PM
- 8:30 AM-3:00 PM
Apply for another child?*
- Yes
- No
Sibling's Information
Child's Name*
Preferred Name / Nickname*
Date of Birth*
Date Format: MM slash DD slash YYYY
Sex*
- Male
- Female
Child's Primary Language*
Language primarily spoken at home*
Start day*
Date Format: MM slash DD slash YYYY
Please choose 5 Day Schedule:*
- 8:30 AM-5:30 PM
- 8:30 AM-3:00 PM

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Payment Options:
Please choose payment option:*
- Single payment plan
- Two installment Plan
- Monthly
Where did you hear about SIMS?*
Registration fee is due at the time of application. Registration fee and deposits are non-refundable.
Please submit this application form and send a $150.00 non-refundable check payable to: SIMS 991 Boylston St, Newton, MA 02461.

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Face Sheet

Please fill out these forms completely. If a question does not apply to your child, write N/A (not applicable). The forms must be in the educator’s possession on or before the first day your child begins care. Please notify your educator if any of the information changes.
General Information
Date of Admission
Date Format: MM slash DD slash YYYY
Age at Admission
Date of Discharge
Date Format: MM slash DD slash YYYY
Reason for Discharge
Allergies/Special Diets
Parent(s)/guardian(s) business address/location during child care:
Parent/Guardian
Where
Telephone
Cell Phone
Instructions
Parent/Guardian
Where
Telephone
Cell Phone
Instructions

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Emergency Contact/Authorized pick-up person
Name
Address
Telephone
Cell Phone
Authorized pick-up person
- Yes
- No
Name
Address
Telephone
Cell Phone
Authorized pick-up person
- Yes
- No
Child's Medical Information
Hospital/Clinic Preference
Physician’s Name
Phone Number
Insurance Company
Policy Number
Allergies/Special Health Considerations
- I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
Check the box beside the statement:
- I release Spanish In Motion and individuals from liability in case of accident during activities related to Spanish Montessori Preschool, as long as normal safety procedures have been taken.
Parent’s/Guardian’s Signature

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Developmental History & Background Information

Please provide information for Infants and Toddlers.
Developmental History
Age began sitting
Age began crawling
Age began walking
Age began talking
Does your child pull up?
- Yes
- No
Does your child crawl?
- Yes
- No
Does your child walk with support?
- Yes
- No
Any speech difficulties?
- Yes
- No
If so, please specify
Special words to describe needs
Language spoken at home
Any history of colic?
- Yes
- No
If so, please specify
Does your child use pacifier or suck thumb?
- Yes
- No
When
Does your child have a fussy time?
- Yes
- No
When
How do you handle this time?
Health
Any known complications at birth?
Serious illnesses and/or hospitalizations
Special physical conditions, disabilities
Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions
Regular medications
Eating Habits
Special characteristics or difficulties
Is infant on a special formula?
- Yes
- No
If infant is on a special formula, describe its preparation in detail
Favorite foods
Foods refused
Is your child fed held in lap?
- Yes
- No
High chair?
- Yes
- No
Does your child eat with spoon?
- Yes
- No
Does your child eat with fork?
- Yes
- No
Does your child eat with hands?
- Yes
- No
Toilet Habits
Are disposable or cloth diapers used?
- Yes
- No
Is there a frequent occurrence of diaper rash?
- Yes
- No
Do you use oil?
- Yes
- No
Do you use powder?
- Yes
- No
Do you use lotion?
- Yes
- No
Other
Are bowel movements regular?
- Yes
- No
How many per day?
Is there a problem with diarrhea?
- Yes
- No
Is there a problem with constipation?
- Yes
- No
Has toilet training been attempted?
- Yes
- No
Please describe any particular procedure to be used for your child at the center
What is used at home?
- Pottychair
- Special child seat
- Regular seat
How does your child indicate bathroom needs (include special words)
Is your child ever reluctant to use the bathroom?
- Yes
- No
Does your child have accidents?
- Yes
- No
Sleeping Habits
Does your child sleep in a crib?
- Yes
- No
Does your child sleep in a bed?
- Yes
- No
Does your child become tired or nap during the day (include when and how long)?
- Please note: The American Academy of Pediatrics has determined that placing a baby on his/her back to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and unexplained death of a baby under one year of age. If your child does not usually sleep on his/her back, please contact your pediatrician immediately to discuss the best sleeping position for your baby. Please also take the time to discuss your child’s sleeping position with your caregiver.
When does your child go to bed at night?
When does your child get up in the morning?
Describe any special characteristics or needs (stuffed animal, story, mood on waking etc)
Social Relationships
How would you describe your child?
Previous experience with other children/day care
Previous experience with other children/day care
Reaction to strangers
Able to play alone?
Favorite toys and activities
Fears (the dark, animals, etc.)
How do you comfort your child?
What is the method of behavior management/discipline at home?
What would you like your child to gain from this childcare experience?
Daily Schedule
Please describe your child’s schedule on a typical day. For infants, please include awakening, eating, time out of crib/bed, napping, toilet habits, fussy time, night bedtime, etc.
Is there anything else we should know about your child?
First Aid & Emergency Medical Care Consent Form
Check the box beside the statement:
- I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate.
Check the box beside the statement:
- I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to the above-mentioned hospital and to secure necessary medical treatment for my child.
Child's Allergies
Chronic Health Conditions

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SIMS Handbook Sign off Sheet
Check the box beside the statement:
- I do understand that all policies listed in this handbook will be enforced and that failure to comply with these policies is reason for immediate termination. I also understand that SIMS maintains the right to change any and all of these policies as deemed necessary throughout the year.

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Transportation Plan and Authorization Form
My child will arrive at the program:
- Parent Drop off
- Supervised Walk
- Unsupervised Walk
- Public/Private/Van
- Program Bus/Van
- Contract/Van
- Private Trans. Arranged by parent
- Other
My child will depart from the program:
- Parent Pick Up
- Supervised Walk
- Unsupervised Walk
- Public/Private/Van
- Program Bus/Van
- Contract/Van
- Private Trans. Arranged by parent
- Other
REFER TO FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM FOR RELEASE INFORMATION

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Photographic and Video Release Form
Parent/Caregiver Name(s)
Occasionally we photograph or videotape classes for promotional purposes. Do we have your permission to use photographs or videos of your child in our online and printed promotional materials, with the agreement that any identifying information, such as names remain anonymous?*
- Yes, Unrestricted usage: I give permission for my child’s image to be used in print, video, and digital media. I agree that these images may be used by Spanish Immersion Montessori School for a variety of marketing and school purposes and that these may be used without further notifying me. I do understand that the child’s last name will not be used in conjunction with any video or digital image.
- No, I deny permission to use my child’s pictures and videos.

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General Permissions Forms
Check the box beside the statement:
- By initialing the following statements, I give permission for my child to participate in the specifically noted activities.
OUTDOOR WALKS to the playground with the Preschool Program.
- Yes
- No
Initials
SUN SCREEN: I hereby authorize Spanish Immersion Montessori School to apply sunscreen mentioned below to my child when going outdoors, or as directed.
- Yes
- No
SUN SCREEN: I will supply my own sunscreen to be applied when going outdoors, or as directed.
- Yes
- No
Initials
PHOTOGRAPHS: I hereby give permission for Spanish Immersion Montessori School to use any pictures, videos, or slides of my child, taken in the course of his/her participation in SIMS, for newsletters and mounted on bulletin boards at School.
- Yes
- No
Initials
STUDENT DIRECTORY: I hereby give permission for SIMS to use my email, phone number and address in the sCHOOL student directory.STUDENT DIRECTORY: I hereby give permission for SIMS to use my email, phone number and address in the sCHOOL student directory.
- Yes
- No
Initials

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Hand Sanitizer Permission Form

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Hubbliville Academy

Enrollment Package 1.0

Step 1 of 11

SIMS Enrollment Package

Parent/Guardian Information

Child's Information

Sibling's Information

Payment Options:

Face Sheet

General Information

Parent(s)/guardian(s) business address/location during child care:

Emergency Contact/Authorized pick-up person

Child's Medical Information

Developmental History & Background Information

Developmental History

Health

Eating Habits

Toilet Habits

Sleeping Habits

Social Relationships

Daily Schedule

First Aid & Emergency Medical Care Consent Form

SIMS Handbook Sign off Sheet

Transportation Plan and Authorization Form

REFER TO FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM FOR RELEASE INFORMATION

Photographic and Video Release Form

General Permissions Forms

Hand Sanitizer Permission Form

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