IRUKA YOCHIEN PRESCHOOL
2120 S. Stimson Ave. Hacienda Heigts, CA 91745
Tel:(626)330-0730 Fax.(626)961-0439
Date:.

.2019

Enrollment Application
Child ’ s Name

M / F

Date of Birth

Potty Trained

AgeHome Address
CityZip

Phone

E-mail address
Adults With Whom Child Lives:
Name

RelationshipWork phone
Name

RelationshipWork Phone
Emergency Contact:

Relationship2 n d Phone

Regular Phone
Physician:Phone

Address
Medical Insurance

Policy#Parent Signature

DateDays Child will be attending:

1 s t choice: M ・ T ・ W ・ Th ・ F

Time:：～：

2 n d choice: M ・ T ・ W ・ Th ・ F

Time:：～：

Note: Entrance Fee□ Registration Fee□
Emergency Kit□

Immunization Rec.□

Photo Permission□

P. Hb.Agremnt.□

Policy Change Agreement□

CALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING

STATE OF CALIFORNIAHEALTH AND HUMAN SERVICES AGENCYPHYSICIAN’S REPORT—CHILD CARE CENTERS(CHILD’S PRE-ADMISSION HEALTH EVALUATION)
PART A – PARENT’S CONSENT (TO BE COMPLETED BY PARENT)__________________________________________, born ________________________________ is being studied for readiness to enter(NAME OF CHILD)(BIRTH DATE)_________________________________________ . This Child Care Center/School provides a program which extends from _____ : ____(NAME OF CHILD CARE CENTER/SCHOOL)

a.m./p.m. to ______ a.m./p.m. , __________ days a week.
Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in thisreport to the above-named Child Care Center.
__________________________________________________________(SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE)_________________(TODAY’S DATE)PART B – PHYSICIAN’S REPORT (TO BE COMPLETED BY PHYSICIAN)
Problems of which you should be aware:
Hearing:

Allergies: medicine:

Vision:Insect stings:

Developmental:

Food:

Language/Speech:

Asthma:Dental:Other (Include behavioral concerns):
Comments/Explanations:
MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)
DATE EACH DOSE WAS GIVENVACCINE

1stPOLIO (OPV OR IPV)DTP/DTaP/DT/Td
MMR(DIPHTHERIA, TETANUS AND[ACELLULAR] PERTUSSIS OR TETANUS
AND DIPHTHERIA ONLY)(MEASLES, MUMPS, AND RUBELLA)(REQUIRED FOR CHILD CARE ONLY)(HAEMOPHILUS B)

HIB MENINGITISHEPATITIS B
VARICELLA(CHICKENPOX)

2nd

3rd

4th

5th//////////////////////////////////////////SCREENING OF TB RISK FACTORS (listing on reverse side)■ Risk factors not present; TB skin test not required.
■ Risk factors present; Mantoux TB skin test performed (unlessprevious positive skin test documented).
___ Communicable TB disease not present.
I have ■have not■reviewed the above information with the parent/guardian.

Physician:_______________________________________________
Address:________________________________________________
Telephone: ______________________________________________

Date of Physical Exam: ___________________________________
Date This Form Completed: _______________________________
Signature ______________________________________________✔
■

LIC 701 (8/08) (Confidential)

Physician✔
■Physician’s Assistant✔ Nurse Practitioner■
PAGE 1 OF 2

RISK FACTORS FOR TB IN CHILDREN:*Have a family member or contacts with a history of confirmed or suspected TB.

*

Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America).

*

Live in out-of-home placements.

*

Have, or are suspected to have, HIV infection.

*

Live with an adult with HIV seropositivity.

*

Live with an adult who has been incarcerated in the last five years.

*

Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents innursing homes.

*

Have abnormalities on chest X-ray suggestive of TB.

*

Have clinical evidence of TB.

Consult with your local health department’s TB control program on any aspects of TB prevention and treatment.

LIC 701 (8/08) (Confidential)

PAGE 2 of 2

STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSINGCHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORTCHILD’S NAMESEXBIRTH DATEFATHER’S/FATHER’S DOMESTIC PARTNER’S NAME

DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME

DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?

DATE OF LAST PHYSICAL/MEDICAL EXAMINATIONDEVELOPMENTAL HISTORY (*For infants and preschool-age children only)
WALKED AT

BEGAN TALKING AT*MONTHSTOILET TRAINING STARTED AT*MONTHS*MONTHS

PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:
DATES
DATES

DATES

■

Chicken Pox■Diabetes■

Poliomyelitis■Asthma■Epilepsy■■Rheumatic Fever■Ten-Day Measles(Rubeola)Whooping cough■■■Hay FeverMumps

Three-Day Measles(Rubella)

SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS■DOES CHILD HAVE FREQUENT COLDS?

YES■NO

HOW MANY IN LAST YEAR?

LIST ANY ALLERGIES STAFF SHOULD BE AWARE OFDAILY ROUTINES (*For infants and preschool-age children only)
WHAT TIME DOES CHILD GET UP?

*WHAT TIME DOES CHILD GO TO BED?

DOES CHILD SLEEP DURING THE DAY?

*DIET PATTERN:BREAKFAST(What does child usually
eat for these meals?)

LUNCHWHEN?

DOES CHILD SLEEP WELL?

**HOW LONG?

**WHAT ARE USUAL EATING HOURS?
BREAKFAST ________________________
LUNCH_____________________________
DINNERDINNER
ANY FOOD DISLIKES?

ANY EATING PROBLEMS?

IS CHILD TOILET TRAINED?

■YES

■

*IF YES, AT WHAT STAGE:*NO

WORD USED FOR “BOWEL MOVEMENT”

ARE BOWEL MOVEMENTS REGULAR?

■YES

■

WORD USED FOR URINATION**WHAT IS USUAL TIME?

*NO*PARENT’S EVALUATION OF CHILD’S HEALTHIS CHILD PRESENTLY UNDER A DOCTOR’S CARE?

■YES■YES■DOES CHILD TAKE PRESCRIBED MEDICATION(S)?

■NO

DOES CHILD USE ANY SPECIAL DEVICE(S):■IF YES, NAME OF DOCTOR:IF YES, WHAT KIND:NOYES■IF YES, WHAT KIND AND ANY SIDE EFFECTS:NO

DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME? IF YES, WHAT KIND:■YES■NOPARENT’S EVALUATION OF CHILD’S PERSONALITYHOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?

HAS THE CHILD HAD GROUP PLAY EXPERIENCES?
DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)

WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?

REASON FOR REQUESTING DAY CARE PLACEMENTPARENT’S SIGNATURE

LIC 702 (8/08) (CONFIDENTIAL)DATESTATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESCONSENT FOR EMERGENCY MEDICAL TREATMENTChild Care Centers Or Family Child Care Homes

AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TOIRUKA YOCHIEN PRESCHOOL_________________________________________TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE
FACILITY NAMEPRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR__________________________________________________ . THIS CARE MAY BE GIVEN UNDERNAMEWHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD
NAMED ABOVE.

CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:DATEPARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE

HOME ADDRESSHOME PHONE

WORK PHONE(()

LIC 627 (9/08) (CONFIDENTIAL))STATE OF CALIFORNIAHEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING DIVISIONIDENTIFICATION AND EMERGENCY INFORMATIONCHILD CARE CENTERS/FAMILY CHILD CARE HOMESTo Be Completed by Parent or Authorized Representative
CHILD’S NAMELASTADDRESSNUMBER

MIDDLEFIRSTSEXTELEPHONE(STREETFATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAMECITYLASTSTATEMIDDLEZIP

FIRST

BUSINESS TELEPHONE(HOME ADDRESSNUMBER

STREETCITYSTATEZIPLASTMIDDLEFIRSTNUMBER

STREETCITYSTATEZIPLAST NAMEMIDDLEFIRST)

HOME TELEPHONE(PERSON RESPONSIBLE FOR CHILD)

BUSINESS TELEPHONE(HOME ADDRESS)HOME TELEPHONE(MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME)BIRTHDATE)HOME TELEPHONE

BUSINESS TELEPHONE(())

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCYNAMEADDRESSTELEPHONE

RELATIONSHIPPHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCYPHYSICIANADDRESSMEDICAL PLAN AND NUMBERDENTISTADDRESSMEDICAL PLAN AND NUMBERTELEPHONE()TELEPHONE()IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

■ CALL EMERGENCY HOSPITAL■ OTHEREXPLAIN: ____________________________________________________________________________________________________________________NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)

NAMERELATIONSHIPTIME CHILD WILL BE CALLED FORSIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVEDATETO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEEDATE OF ADMISSION

LIC 700 (8/08)(CONFIDENTIAL)DATE LEFTSTATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESPERSONAL RIGHTS
Child Care Centers
Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.
(a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are
not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons.
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/herneeds.
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,
threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with dailyliving functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids tophysical functioning.
(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of theprovisions of law regarding complaints including, but not limited to, the address and telephone number of thecomplaint receiving unit of the licensing agency and of information regarding confidentiality.
(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisorof his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely
voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits fromspiritual advisors shall be made by the parent(s), or guardian(s) of the child.
(6) Not to be locked in any room, building, or facility premises by day or night.
(7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing
agency.
THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE
LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

Community Care Licensing
NAME

1000 Corporate Canter Dr. Ste 500
ADDRESS

Monterey Park, CACITY

91745(323)981-3350

ZIP CODEAREA CODE/TELEPHONE NUMBERDETACH HERE
TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE:

PLACE IN CHILD'S FILE

Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:
ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in theCalifornia Code of Regulations, Title 22, at the time of admission to:(PRINT THE NAME OF THE FACILITY)

IRUKA YOCHIEN PRESCHOOL(PRINT THE ADDRESS OF THE FACILITY)

2120 S Stimson Ave Hacienda Heights, CA 91745(PRINT THE NAME OF THE CHILD)(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN)

LIC 613A (8/08)(DATE)STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING DIVISIONCHILD CARE CENTERNOTIFICATION OF PARENTS’ RIGHTS
PARENTS’ RIGHTS
As a Parent/Authorized Representative, you have the right to:1.

Enter and inspect the child care center without advance notice whenever children are in care.

2.

File a complaint against the licensee with the licensing office and review the licensee’s public file
kept by the licensing office.

3.

Review, at the child care center, reports of licensing visits and substantiated complaints against thelicensee made during the last three years.

4.

Complain to the licensing office and inspect the child care center without discrimination or retaliation
against you or your child.

5.

Request in writing that a parent not be allowed to visit your child or take your child from the childcare center, provided you have shown a certified copy of a court order.

6.

Receive from the licensee the name, address and telephone number of the local licensing office.
Licensing Office Name:

Community Care Licensing_________________________________________________

Licensing Office Address:

1000 Corporate Center #200B Monterey Park, CA 91754_________________________________________________

Licensing Office Telephone #:(323)981-3350_________________________________________________

7.

Be informed by the licensee, upon request, of the name and type of association to the child carecenter for any adult who has been granted a criminal record exemption, and that the name of theperson may also be obtained by contacting the local licensing office.

8.

Receive, from the licensee, the Caregiver Background Check Process form.

NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO A
PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVEPOSES A RISK TO CHILDREN IN CARE.
For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov
LIC 995 (9/08)(Detach Here - Give Upper Portion to Parents)

A C K N O W L E D G E M E N T O F N O T I F I C AT I O N O F PA R E N T S ’ R I G H T S(Parent/Authorized Representative Signature Required)I, the parent/authorized representative of ________________________________________________, havereceived a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and the
CAREGIVER BACKGROUND CHECK PROCESS form from the licensee.
IRUKA YOCHIEN PRESCHOOL_____________________________________Name of Child Care Center________________________________________________________________

Signature (Parent/Authorized Representative)

Date

NOTE:

This Acknowledgement must be kept in child’s file and a copy of the Notification given to
parent/authorized representative.
For the Department of Justice “Registered Sex Offender”database go to www.meganslaw.ca.gov

LIC 995 (9/08)

＜注射記録を添付して下さい＞
以下の注射を受けているかどうかを確認する必要があります。
1.Polio
2.DTP/DT/Td
3.MMR
4.HIB
5.Hep B
6.Varicella

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<Attach your immunization record>
You need to be immunized by the following injections.
1.Polio
2.DTP/DT/Td
3.MMR
4.HIB
5.Hep B
6.Varicella

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