Confidentiality Policy
2023 Parent Handbook
2023 Holiday Calendar
Childcare Partnership Program Form

Insurance Information Request

Insurance Information Update

Please complete the following information regarding your child,

It is necessary that we have updated insurance information on file for your child while in our care. It is imperative that the information you provide is accurate and current. All information provided is for the child named above.

Max. file size: 100 MB.
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Special Diet Statement

SPECIAL DIET STATEMENT

The child named below is a participant in the U.S. Department of Agriculture Child and Adult Care Food Program (CACFP). La Crèche, as the child care provider is required to provide meals according to the minimum requirements for the Child Adult Care Food Program.
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Check the appropriate statement and include recommended alternates.

In place of breast milk or iron fortified infant formula: Infant (8 through 12 months) approved to be served (circle one): whole milk, reduced fat (2%) milk, low-fat (1%) milk, or skim (nonfat) milk

Non-Iron-Fortified Infant Formula substituted for Iron-Fortified Infant Formula for an infant under 12 months. Agency provides Iron-Fortified Infant Formula.

NOTE: Infants do not require a Special Diet Statement for soybean-based formula

Other - Agency, Kitchen prepared Meals served daily to all enrolled children of the appropriate age.
Parent, Legal Guardian or Medical Authority

"The USDA is an equal opportunity provider and employer"

Photo Release

La Crèche Early Childhood Centers, Inc. 1800 Olson Memorial Highway Minneapolis, MN 55411 612-377-1786 1120 Oliver Ave. N Minneapolis, MN 55411 612-521-4384 www.lacrechekids.org [email protected]

Photo Release Form

With my signature below I grant permission for my child(ren) to be photographed, or their images recorded for print or electronic use in promoting La Crèche services and program partnerships. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses. I agree that this form will remain in effect during the term of my child's enrollment. I understand that there will be no payment for me or my child's participation in this release.
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Email Request Form

If it is easier to email us your information, please feel free to do so via the following email [email protected]

Please make sure you include your full name and identify your child(ren) by name.

Childcare Immunization Form

Child Care Immunization Form

Must be on file before a child attends child care
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Minnesota law requires children enrolled in child care to be immunized against certain diseases or file a legal medical or conscientious exemption.
You may attach a copy of the child's immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or laboratory evidence of immunity and CO for vaccines that are contrary to parent or guardian's conscientiously held beliefs.
For updated copies of your child's vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 800-657-3970.
Type of Vaccine DO NOT USE (✓) or (*)
Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please that are no write the date in the shaded box.)

Diphtheria, Tetanus, and Pertussis (DTaP, DTP)

• 3 doses during 1st year (at 2-month intervals)
• 4th dose at 12-18 months
• 5th dose at 4-6 years
Indicate vaccine type: DTaP or DTP
5th dose not required if 4th dase was given on or after the 4th birthday

Polio (IPV, OPV)

• 2 doses in the first year
• 3rd dose by 18 months
• 4th dose at 4-6 years
4th dose not required if 3rd dose was given on or after the 4th birthday

Measles, Mumps, and Rubella (MMR)

• Required for children 15 months and older
• 1st dose on or after 1st birthday
• 2nd dose at 4-6 years

Haemophilus influenzae type b (Hib)

• 2-3 doses in the first year
• 1 dose required after 12 months or older
• For unvaccinated children 15-59 months, 1 dose is required
• Not required for children 5 years or older

Varicella (chickenpox)

• Required for children 15 months and older
• 1st dose on or after 1st birthday
• 2nd dose at 4-6 years

Pneumococcal Conjugate Vaccine (PCV)

• Required for children age 2 - 24 months
• 3 doses in the first year
• 4th dose after 12 months
• At least 1 dose is recommended for children 24-59 months in child care

Hepatitis B (hep B)

• 2-3 doses in the first year
• 3rd dose (final dose) by 18 months

Hepatitis A (hep A)

• 2 doses separated by 6 months for children 12 months and older

Recommended

Rotavirus (2-3 doses between 2 and 6 months)
Influenza (annually for children 6 months or older)
Instructions, please complete:
Box 1 to certify the child's immunization status
Box 2 to file an exemption (medical or concientious)
1. Certify Immunization Status. Complete A or B to indicate child's immunization status.
A. Children who are 15 months or older:
For children who are 15 months or older and who have received all the immunizations required by law for child care:

I certify that the above-named child is at least 15 months of age and has completed the immunizations which are required by law for child care.
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B. Children who are younger than 15 months:
For children who are younger than 15 months OR have not received all required immunizations: Developed by the Minnesota Department of Health - Immunization Program
>br> I certify that the above-named child has received the immunizations indicated. In order to remain enrolled this child must receive all required vaccines within 18 months from initial enrollment date. The dates on which the remaining doses are to be given are:
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2. Exemptions to Immunization Law. Complete A and/or B to indicate type of exemption.

A. Medical exemption:

No child is required to receive an immunization if they have a medical contraindication, history of disease, or laboratory evidence of immunity. For a child to receive a medical exemption, a physician, nurse practitioner, or physician assistant must sign this statement:

I certify the immunization(s) listed below are contraindicated for medical reasons, laboratory evidence of immunity, or that adequate immunity exists due to a history of disease that was laboratory confirmed (for varicella disease see below). List exempted immunization(s):
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Conscientious exemption:


No child is required to have an immunization that is contrary to the conscientiously held beliefs of his/her parent or guardian. However, not following vaccine recommendations may endanger the health or life of the child or others they come in contact with. In a disease outbreak, children who are not vaccinated may be excluded in order to protect them and others. To receive an exemption to vaccination, a parent or legal guardian must complete and sign the following statement and have it notarized: I certify by notarization that it is contrary to my conscientiously held beliefs for my child to receive the following vaccine(s):
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CACFP-Form

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2022 and Ongoing -

Dear Parent/Guardian:

We provide nutritious meals every day to the children at our center.
The Child and Adult Care Food Program (CACFP) helps our center to pay for meals. The amount of help we get depends on the incomes of households with children in care. Please complete the enclosed CACFP Household Income Statement form following the instructions. If your household income is higher than the guidelines shown on the instructions page, please write "over income" on the Household Income Statement, include your children's names, and return the form.

Return your completed Household Income Statement form to:
La Crèche Early Childhood Centers, Inc. - Your child's classroom or the Administrative Office.

Commonly Asked Questions:

I already get MFIP or SNAP benefits. Do I meet CACFP income guidelines? Yes. You should provide your case number on the form instead of income information if anyone in your household is approved for one of these programs: Minnesota Family Investment Program (MFIP), Supplemental Nutrition Assistance Program (SNAP) or Food Distribution Program on Indian Reservations (FDPIR).

In addition, foster children meet CACFP guidelines without providing income information.

Your household may meet CACFP income guidelines if you are approved for the Women, Infants, and Children program (WIC) or Medical Assistance program (MA). Please fill out a Household Income Statement form.

Who should I include as members of my household? Include yourself and all other people living in your household, related or not (such as grandparents, other relatives or friends). Include anyone who is temporarily away, for example a college student.

What if my income is not always the same? List the amount that you normally get. Include overtime pay if you regularly work overtime. For fluctuating income like seasonal work, list the average monthly income.

Do I need to provide my Social Security number? If household incomes are reported on the form, the person signing the form must write in just the last four digits of their Social Security number. If you don't have a Social Security number, indicate that on the form.

May I fill out a Household Income Statement if someone in my household is not a U.S. citizen? Yes. You or your children or other household members do not have to be U.S. citizens for you to fill out a CACFP Household Income Statement.

How will my information be kept? We will keep your information on file as private data. The back page of the form has more information about data privacy.

If I don't qualify now, may I apply later? Yes. Please complete a Household Income Statement form at any time if your income goes down, your household size goes up, or you start getting SNAP, MFIP or FDPIR benefits.

If you have other questions or need help, call 612-377-1786.

Sincerely,
La Crèche Early Childhood Centers, Inc. - Administration

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How to Complete the Household Income Statement Form

Fill out a Child and Adult Care Food Program-Household Income Statement if any of the following apply:

Any person in your household currently participates in one of these programs: Minnesota Family Investment Program (MFIP), Supplemental Nutrition ance Program (SNAP), or Food Distribution Program on Indian Reservations (FDPIR), or

You have one or more foster children in the household (a welfare agency or court has legal responsibility for the child), or to the income shown below for your household size. Include any foster children as members of the household. Do not include as income: foster care payments, federal education benefits, MFIP payments, or value of assistance received from SNAP, WIC, or FDPIR. Military: Do not include combat pay or assistance from the Military Privatized Housing Initiative. The income guidelines are effective from July 1, 2022 through June 30, 2023.

Maximum Total Income
1 25.142 2,096 1.048 967 484
2 33,874 2,823 1,412 1,303 652
3 42,606 3,551 1,776 1,639 820
4 51,338 4,279 2,140 1,975 988
5 60,070 5,006 2.503 2.311 1,156
6 68,802 5.734 2,867 2,647 1,324
7 77,534 6,462 3,231 2,983 1,492
8 86,266 7,189 3,595 3.,318 1,659
Add for each additional person 8.732 728 364 336 168

1 - Children to List

List all infants and children in the household and their birthdates, even if they are not related. Attach another page if needed to list all children. Fill in circles to show which children are enrolled at this child care center. If any children are foster children, fill in the circle.

Providing ethnic and racial information for each child is optional and does not affect approval for CACFP benefits. This information helps to make sure we are fully serving our community.

2- Case Number

If any household member currently participates in SNAP, MFIP or FDPIR assistance programs, check the box to indicate which assistance program and write in the corresponding case number. Then go to number 4. If no one in your household participates in SNAP, MFIP or FDPIR, leave number 2 blank and continue on to number 3.

NOTE: Benefits received from Child Care Assistance, Medical Assistance (MA), Women, Infants, and Children H
(WIC), and Person Master Index (PMI) numbers do not qualify for this purpose and cannot be reported on the
Household Income Statement in number 2.

3 - Adults / Incomes / Last Four Digits of Social Security Number

  • If any children have regular earning, write in the amount of income and fill in a circle for frequency. Do
    yillidia not write in an hourly wage. Do not include occasional earnings like babysitting or lawn mowing.
  • List all adults living in the household (everyone not listed in number 1) whether related or not, such as
    Taupe grandparents, other relatives, or friends. Include any adult who is temporarily away from home, like a
    student away at college. Attach another page if necessary.
  • List gross incomes before deductions, not take-home pay. Do not list an hourly wage rate. For adults with no income to report, enter a 'O' or leave the section blank. This is your certification (promise) that there is no income to report for this adults.
  • For each income, fill in a circle to show how often the income is received: weekly, every two weeks, twice per month, or monthly. For fluctuating income like seasonal work, list average monthly income.
  • For farm or self-employment income only, list the net income per year or month after business expenses. A loss from farm or self-employment must be listed as 0 income and does not reduce other income.
  • The adult household member signing the form must provide the last four digits of their Social Security number or check the box if they do not have a Social Security Number.

4- Signature and Contact Information

An adult household member must sign and date the form.

Child Enrollment Documentation for Child Care Centers Participating in the Child and Adult Care Food Program (CACFP)

Child Care Centers that participate in the Child and Adult Care Food Program (CACFP) are required to collect annual enrollment information from parents and/or guardians. This requirement applies to all CACFP facilities except adult day care centers, emergency shelters, outside-school-hours care centers and at-risk centers.

The enrollment form must include the following elements per regulations 7 CFR § 226.15(e)(2) and § 226.17(b)(8)):

  • Each enrolled child's normal days
  • Hours in care
  • Meal service received
  • Signature of parent or guardian.
  • Annual updating of the information.

To document enrollment information, child care centers who participate in the Child and Adult Care Food Program (CACFP) can use the attached sample enrollment form or can modify their own child care enrollment form to include the required elements listed above.

Enrollment forms need to be updated annually by a parent or guardian. If the child's normal days that he/she attends the day care, their hours in care, the meal services they receive and contact information stays the same as what was reported on their original form, the parent or guardian can simply initial and date the form at the bottom. If only a few changes are needed the parent or guardian can simply modify the existing form and initially and date the form at the bottom. If there are significant changes that need to be made have the parent or guardian complete a new form.

If you have any questions about the requirement for collection of enrollment information, please contact Food and Nutrition Services (FNS) at 651-582-8526, 800-366-8922 or email [email protected].

Child Enrollment Form-Child and Adult Care Food Program

Dear Parents or Guardians,
Your child care center participates in the U.S. Department of Agriculture's (USDA) Child and Adult Care Food Program (CACFP) which ensures healthy meals are served to your children. To meet CACFP requirements specific enrollment information must be collected annually. Please complete this form and return it to your child care center.
Name of the Child Care Center:

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Schedule

Enter the normal hours your child is in care*

Check the meals your child normally receives while in care:

*(for example, 7:30 a.m. -5 p.m.; for a split schedule, 7:30 a.m.-9 a.m. and 12:30 p.m.-5 p.m.)
Weekdays
Weekends
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MM slash DD slash YYYY

Schedule

Enter the normal hours your child is in care*

Check the meals your child normally receives while in care:

*(for example, 7:30 a.m. -5 p.m.; for a split schedule, 7:30 a.m.-9 a.m. and 12:30 p.m.-5 p.m.)
Weekdays
Weekends
You have the option of providing your own IFIF, providing expressed breastmilk or breastfeed on-site. Please indicate your preference (choose one or more):
The center will introduce semi-solid foods to your infant according to the decisions made by you and your infant's doctor.

If there are other children in care, please complete additional forms as needed.

Address
Child enrollment information needs updates annually. If the above information is the same, initial and date below.
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Child and Adult Care Food Program - Child Care Centers Household Income Statement - July 2022

1. List all infants, children and students through grade 12 in the household, even if they are not related. If more space is needed, attach another sheet.

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If yes, select one or more ckeckboxes for each child. Ethnicity and Race are Optional

Race - One or more may be selected
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If yes, select one or more ckeckboxes for each child. Ethnicity and Race are Optional

Race - One or more may be selected
MM slash DD slash YYYY
Race - One or more may be selected
MM slash DD slash YYYY
Race - One or more may be selected
2. Do any household members currently participate in SNAP, MFIP, or FDPIR? If yes, check which program and write the corresponding case number below: Go on to number 4. If no, go to number 3. NOTE: Child Care Assistance, Medical Assistance, WIC benefits, and PMI numbers do not qualify under this section
2. SNAP Case number
MFIP Case number
FDPIR Case number
3. Report income for all household members. Skip this step if you answered yes to number 2 or if all participants are foster children.
A. Child Income. Include the total income a child earns or receives. Child Income:
B. Adult Income. Include yourself and record total income below. List all adult household members even if they don't receive income.
List the full name of each household member who is living with you and shares income and expenses. Enter all income(s) in whole dollars. If zero income write 0. Include any college students temporarily away.

Gross Pay from Work

Do not write in an hourly wage

Net Income after business expenses. State if annual or monthly.

Public Assistance, Child Support, Alimony

All other income

List the full name of each household member who is living with you and shares income and expenses. Enter all income(s) in whole dollars. If zero income write 0. Include any college students temporarily away.

Gross Pay from Work

Do not write in an hourly wage

Net Income after business expenses. State if annual or monthly.

Public Assistance, Child Support, Alimony

All other income

List the full name of each household member who is living with you and shares income and expenses. Enter all income(s) in whole dollars. If zero income write 0. Include any college students temporarily away.

Gross Pay from Work

Do not write in an hourly wage

Net Income after business expenses. State if annual or monthly.

Public Assistance, Child Support, Alimony

All other income

or I don't have a Social Security Number.
4. I certify (promise) that all information on this application is true and correct and all household members and incomes are reported. I understand that this information is given in connection with receipt of federal funds and that officials may verify (check) the information. I understand that if I purposely give false information, I may be prosecuted under applicable federal and state laws.
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Sponsor Use Only-Do Not Write Below

Approved:
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Allergy Form (2)

La Crèche Early Childhood Centers, Inc.

1800 Olson Memorial Highway Minneapolis, MN 55411 612-377-1786
1120 Oliver Ave. N Minneapolis, MN55411
www.lacrechekids.org         [email protected]

ALLERGY FORM

SITE La Crèche / North II (Circle One)

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MM slash DD slash YYYY

An Individualized Child Care Plan for Allergies listed, must be completed by the child's physician before childcare can begin.

Childcare Immunization Form 1

Child Care Immunization Form

1800 Olson Memorial Highway Minneapolis, MN 55411 612-377-1786
1120 Oliver Avenue North Minneapolis, MN 55411 612-521-4384
Must be on file before a child attends child care
MM slash DD slash YYYY
Minnesota law requires children enrolled in child care to be immunized against certain diseases or file a legal medical or conscientious exemption.
You may attach a copy of the child's immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or laboratory evidence of immunity and CO for vaccines that are contrary to parent or guardian's conscientiously held beliefs.
For updated copies of your child's vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 800-657-3970.
Type of Vaccine DO NOT USE (✓) or (*)
Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please that are no write the date in the shaded box.)

Diphtheria, Tetanus, and Pertussis (DTaP, DTP)

• 3 doses during 1st year (at 2-month intervals)
• 4th dose at 12-18 months
• 5th dose at 4-6 years
Indicate vaccine type: DTaP or DTP
5th dose not required if 4th dase was given on or after the 4th birthday

Polio (IPV, OPV)

• 2 doses in the first year
• 3rd dose by 18 months
• 4th dose at 4-6 years
4th dose not required if 3rd dose was given on or after the 4th birthday

Measles, Mumps, and Rubella (MMR)

• Required for children 15 months and older
• 1st dose on or after 1st birthday
• 2nd dose at 4-6 years

Haemophilus influenzae type b (Hib)

• 2-3 doses in the first year
• 1 dose required after 12 months or older
• For unvaccinated children 15-59 months, 1 dose is required
• Not required for children 5 years or older

Varicella (chickenpox)

• Required for children 15 months and older
• 1st dose on or after 1st birthday
• 2nd dose at 4-6 years

Pneumococcal Conjugate Vaccine (PCV)

• Required for children age 2 - 24 months
• 3 doses in the first year
• 4th dose after 12 months
• At least 1 dose is recommended for children 24-59 months in child care

Hepatitis B (hep B)

• 2-3 doses in the first year
• 3rd dose (final dose) by 18 months

Hepatitis A (hep A)

• 2 doses separated by 6 months for children 12 months and older

Recommended

Rotavirus (2-3 doses between 2 and 6 months)
Influenza (annually for children 6 months or older)
Instructions, please complete:
Box 1 to certify the child's immunization status
Box 2 to file an exemption (medical or concientious)
1. Certify Immunization Status. Complete A or B to indicate child's immunization status.
A. Children who are 15 months or older:
For children who are 15 months or older and who have received all the immunizations required by law for child care:

I certify that the above-named child is at least 15 months of age and has completed the immunizations which are required by law for child care.
MM slash DD slash YYYY
B. Children who are younger than 15 months:
For children who are younger than 15 months OR have not received all required immunizations: Developed by the Minnesota Department of Health - Immunization Program
>br> I certify that the above-named child has received the immunizations indicated. In order to remain enrolled this child must receive all required vaccines within 18 months from initial enrollment date. The dates on which the remaining doses are to be given are:
MM slash DD slash YYYY

2. Exemptions to Immunization Law. Complete A and/or B to indicate type of exemption.

A. Medical exemption:

No child is required to receive an immunization if they have a medical contraindication, history of disease, or laboratory evidence of immunity. For a child to receive a medical exemption, a physician, nurse practitioner, or physician assistant must sign this statement:

I certify the immunization(s) listed below are contraindicated for medical reasons, laboratory evidence of immunity, or that adequate immunity exists due to a history of disease that was laboratory confirmed (for varicella disease see below). List exempted immunization(s):
MM slash DD slash YYYY
MM slash DD slash YYYY

B. Children who are younger than 15 months:


No child is required to have an immunization that is contrary to the conscientiously held beliefs of his/her parent or guardian. However, not following vaccine recommendations may endanger the health or life of the child or others they come in contact with. In a disease outbreak, children who are not vaccinated may be excluded in order to protect them and others. To receive an exemption to vaccination, a parent or legal guardian must complete and sign the following statement and have it notarized:
MM slash DD slash YYYY

Auth of Use & Disclosure of Protected Health Info

Authorization of Use and Disclosure of Protected Health Information

MM slash DD slash YYYY
Address
I authorize The Family Partnership Developmental Therapy Staff
Name/Organization: La Creche Early Childhood Center
The requested Information to be disclosed:
The purpose of the requested records will be used for:

The release records should cover the following time period:

MM slash DD slash YYYY
MM slash DD slash YYYY
I understand that these records are protected under Federal and State laws and regulations and cannot be disclosed without written consent unless otherwise provided in the statutes.
I understand that this consent and authorization will be in effect for a period of 1 year following the date of signature and must not be expired by the date received. During this year, alterations or exclusions may be made upon a written notice to The Family Partnership.
I understand that I have a right to revoke this authorization at any time. I understand that if I stop this authorization, I must do so In writing to the Health Information Officer. I understand that stopping this authorization will not apply to Information that has already been released or disclosed.
I understand that my health record may include Information relating to mental or behavioral health, chemical dependency, child abuse sickle cell anemia, genetic conditions, acquired immunodeficiency syndrome (AIDS), and/or human immunodeficiency virus (HIV). If I don't want these to be release, I will place a check mark here:
I don't want the following records released:
I understand that authorizing the release of this health information is voluntary. I can refuse to sign this authorization. I understand that I may Inspect or copy the information to be used or disclosed. I understand that any disclosure of Information carries with it the potential for re-disclosure and the information may not be protected by federal privacy rule.
I understand that treatment or payment for services are not contingent upon the signing of this authorization form.
I understand that information at The Family Partnership is limited to staff whose work assignments reasonably require access to my individual file to provide me with appropriate services
MM slash DD slash YYYY
MM slash DD slash YYYY
The Family Partnership: Developmental Therapies 1501 Xerxes Ave N Minneapolis, MN 55411 Main: 612-294-2666 Fax: 612-294-2665