2021-2022 Parent Handbook - Augusta Road Baptist Church Preschool Program - 1823 Augusta Street Greenville, SC 29605

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2021-2022 Parent Handbook
  Augusta Road Baptist Church
      Preschool Program

           1823 Augusta Street
          Greenville, SC 29605
            (864) 232-2713
Table of Contents

                                                .... 2

Fees
Waiting List
General Policies
Medical Policies                                 . 10
COVID-19 Wellness Procedures
                                                   .14
Financial Policy                                     5
Acknowledgement/Agreement                       ... 16

                                                     1
Dear Parents,
      We are happy you have chosen the Augusta Road Baptist Church Preschool Program

handbook will provide you with policies and procedures that guide our program.
       The ARBC Preschool Program offers a nurturing preschool and nursery environment
where we will love and respect your child. We offer a full-time, year-round program
available for children six weeks old through four years old with an early-stay option. Our

is a focus, as well as their social, physical, emotional, and intellectual needs. By teaching to
the South Carolina Early Learning Standards, teachers are able to meet these varied needs of
children at their own level of development.
        We are here to serve you and your family. Working together, we can help your child
experience a Christ-centered early education environment that promotes healthy development.
Whenever possible, the teachers and I welcome you to volunteer in the classroom, be
                                                                             any way you are
able!
        Please know that I am here to help you and your child. If you have any questions or
concerns, please feel free to contact me by email (weekday@arbc.com), phone (864-232-
2713), or make an appointment with me during my office hours of 8:00 a.m.- 4:00 p.m.
        Thank you for choosing Augusta Road Baptist Preschool for early education of your
child. We appreciate and work to honor your trust and support.

Mandy Anderson, Director

                                                                                               2
Introduction

The ARBC Preschool Program offers a combination of curriculum for ages six weeks through
four years old. Our program offers a combination of curriculum designed to meet the spiritual,
social, physical, emotional, and intellectual needs of each child. We include age
appropriate educational content, as well as physical education, music, and a weekly visit to
the sanctuary for chapel time.

Our staff has been with us for an average of four years, with a few staff members having
been employed at our preschool for over ten years. Lead teachers in the 2K, 3K and 4K
classes have degrees in early childhood education. All of our classrooms have at least one
teacher who has early childhood development education, training, and experience. Staff
members have all received background screening, fingerprint checks, TB tests, and health
                                     nges from high school diplomas and completion of the
SC Early Childhood certification; to over 10 years of experience; to Bachelor's Degrees in
early childhood or elementary education. All teachers are required to have 15 hours of
continuing education in early childhood education each year.

The Preschool Program is open from 7:30 a.m. 6:00 p.m. year round, Monday through
Friday, with early stay from 7:30 a.m. 8:30 a.m. for those who need it. Our infant and
toddler care includes this early-stay option with the tuition. We follow Greenville County
Schools for inclement weather. Due to the new eLearning days

                                              Fees

The annual non-refundable registration fee is $200.00.
The monthly tuition for the 2021-2022 school year is as follows:

 Infant 1                                     7:30 a.m.    6:00 p.m.          $795.00

 Infant 2 / Toddlers                          7:30 a.m.    6:00 p.m.          $780.00

 2K - 4K                                      7:30 - 8:30 a.m. (early stay)   $60.00

 September 1st birthday cut-off for each      8:30 a.m.    4:00 p.m.          $630.00
 class
                                              8:00 a.m.    5:30 p.m.          $685.00

                                              8:30 a.m.    6:00 p.m.          $685.00

                                                                                             3
Tuition may be paid online through an emailed QuickBooks link, by check, setting up an
automatic draft from your account. No cash payments will be accepted. Monthly tuition fees
are invoiced on the 1st of each month and are due by the 10th. A late fee of $30 will be
assessed if not paid in full by the 10th. In order to continue attending the preschool program,
the tuition and late fee must be paid within two weeks of receiving your late notice. Tuition
will not be prorated for inclement weather, family vacations, in-service days, early closings or
late openings, illness of the child, unforeseen public health concerns, or withdrawal. All active
church members will receive a 15% discount on preschool tuition.

                                            Waitlist

We typically have a waiting list for all of our classrooms. To be added to this list, please
access our online form here. We encourage you to email or call us monthly to remain active
on this list. After we have confirmed a place for your child, we will call you to arrange a tour
of our facility. Due to COVID-19 procedures, tours will be conducted before or after
operating hours, when children are not present. Active church members receive first priority of
openings, followed by those who have siblings already enrolled in the ARBC Preschool
program.

For more information, please contact the Preschool Program office at (864) 232-2713 or
email Mandy Anderson at weekday@arbc.com.

                                                                                                4
General Policies of the Preschool Program

Age of Child - A child shall be the age of the preschool class in which he/she is enrolled by
September 1st of that year.
Attendance - Please have your child to school by 8:30 a.m. each morning, but no later than
9:00 a.m. This promotes a healthy routine for your child. They will feel more a part of the
group when they are present for all morning activities. If you know that your child will be

so that they can prepare for the smoothest transition to classroom activities.
Clothes - washable, weather appropriate play clothes are the most suitable. Seasonally
                                                                     . Please send your child
in shoes while in Infant 2 through 4K classrooms. Tennis shoes are the best choice to ensure
safety. Flip flops, crocs, and shoes without backs are prohibited. Shoes should have a strap
                                                                          ot. Water shoes are
required for summer water play days. Please label all clothing, lunch boxes, and diaper bags.
Food - Please make sure your child has a nutritious breakfast before arrival; breakfast may not
be brought into the classroom to eat. Parents provide lunch, and the preschool provides
morning and afternoon snacks. Lunches should be healthy, limiting sugar intake. Due to limited

pack. This applies to Infant 2 through 4K classes. Only milk and yogurt should be put in the
refrigerator. Please do not send frozen items that require a long time to heat. Foods that
pose a choking hazard for children under four are not allowed. They are as follows: nuts,
popcorn, marshmallows, and chewing gum. Carrots, hot dogs, bananas, celery, grapes, and
unpeeled fruit such as apples, pears, and peaches should not be sent for your child to eat
                                                                       epared ready-to-eat.
                                          -sized pieces, while toddlers should be ¼ inch
pieces. Please separate foods that need warming from cold foods (i.e. separate fresh fruit
from macaroni that needs to be warmed), and be courteous of the time involved in food
preparation. Please do not send in Gatorade or fruit juices/drinks.
Nut Free Facility- Due to the severe nut allergies in the preschool, we are no longer
allowing peanut butter, peanuts, or tree nuts in any of the classrooms.
Primary Care Teachers - High-quality relationship-based care is central to optimal early brain
development, emotional regulation, and learning. To promote this type of care, Infant 1 and 2
teachers will be primary caregivers. Consistent, responsive, and meaningful interactions with

assigned to one specific infant teacher who is principally responsible for that child in the care
                                                   lude: fostering a relationship with the child

                                                                                                5
and his or her family; observing, documenting, and planning
and learning on an ongoing basis; supporting the child through transitions; carrying out the
                           e routines; and providing emotional support. Primary care does not
mean exclusive care. It means, however, that all infant care program staff know who has
primary responsibility for each child during transitions, during care routines, and when
providing emotional and relational support.
Pacifiers - Pacifiers are only allowed in infant classrooms (Infant 1 and Infant 2). Pacifiers

written on paci. No pacifiers with ani                             , are allowed due to DSS
regulations. While sleeping, pacifiers must not be attached to any holders. Please consider
bringing in a separate pacifier for sleeping.
Bottle and Sippy Cup Policy - Due to DHEC regulations, a clean (sanitized) sippy cup or
bottle must be used for each meal or snack. In order to be in compliance, all bottles must be

should be labeled with the child's name. Teachers cannot rinse bottles or sippy cups and
reuse them during the day. Teachers use the BrightWheel app to track each child
activity. Through the parent app, you will be able to see when each feeding occurs and how
much was consumed.
Cups - cups for toddler, 2K, 3K, and 4K classes must
Health - only well children can be accepted each day. If symptoms of illness are observed,
the parent will be contacted. Care will be given until prompt pickup arrangements can be
made. The child should not return to school until all danger of contagion is past. A child
shall not return to school until 24 hours after he/she is fever free without the aid of
medication (Tylenol or Motrin). (Please see the Medical Policies of the Preschool Program
concerning ill children.)
Special Needs - The Preschool Program accepts children with special needs based on the
available resources of the program. We make every accommodation within our available
resources to meet the unique needs of every child.
Biting - Biting is a normal stage for infants and toddlers. We do not remove infants and
toddlers from the program for biting. In the event of a biting incident, a note will be sent to
the parents of the biter and victim through Brightwheel. Teachers will redirect the biter and try
to determine triggers of the behavior. If we do not have cooperation from the parent or
guardian, we will remove the child from our Preschool Program. Biting beyond the toddler
stage becomes a behavioral issue and will be taken seriously. See Discipline Policy.
Parties, Gifts, and Invitation - Teachers will make suggestions regarding refreshments for
birthday parties held at school. Taking the feelings of every child into consideration, we ask

                                                                                                 6
that invitations not be given out in class unless one is given to each child. Balloons are
prohibited.
Television - Television will be minimal and used as a supplement to enhance the daily
program. Only movies rated G, or shows TV-Y will be approved by the director. When
                                                                                        same
guidelines.
Toys - Classrooms have toys and equipment. Please do not allow your child to bring toys

war toys are prohibited. With teacher approval, favorite books and appropriate music may
be shared.
Pickup and Drop-Off Parents will use the drive thru lane under the portico for their child to
be dropped off outside the preschool with a staff member or volunteer and then taken to
his/her classroom. Parents will use this same process to pick up children in the afternoon.
Display your KidCheck car tag in your dashboard each morning so it can easily be scanned
to check in your child.
     Drop-off in the morning is 7:30 a.m. - 8:30 a.m. and pick up is 4:30 p.m. - 6:00
       p.m. using the drive thru lane. If you drop off or pick up between these times, please
       park in the lot, use Brightwheel app to
       arrived, and wait in the lobby until a staff member comes to check-in your child and
       take them to the classroom.
     2021 ARBC Carpool Traffic Flow Map If you have children in both the ARBC
       preschool and after-school or summer camp programs, please use the preschool drop
       off lane in the mornings to drop off all children. For afternoon pickup, you will need to
       use the summer camp lane to pick up your older child, then continue forward to pick
       up your preschooler.
     No parents will be allowed onto the preschool hall at any time. To minimize the
       number of people in the lobby for safe distancing and to minimize contamination, we
       ask that parents only come into the preschool lobby if absolutely necessary.
    ● When someone other than a parent or guardian is to pick up your child, you must

        office at (864) 232-2713. Picture identification must be presented when the teacher
        in charge does not know the person picking up the child. The guardian should use the
        security call box to notify staff member of their arrival and gain entry to the preschool.
    ● If your child is on the playground at pickup time, you must come to the lobby and a
        teacher will bring your child to you as children are not allowed to leave unassisted and
        cannot climb or be lifted over the fence.
Records - The Preschool Program keeps records of attendance, health, and fees for each
child. A South Carolina Certificate of Immunization must be provided at the time of

                                                                                                7
enrollment and updated as indicated by a physician. Telephone numbers where parents
can be reached at all times must be provided. Emergency contact person must be located in

School Schedule Unless otherwise announced, we follow the Greenville County Schools
for inclement weather. When the public schools are closed due to weather conditions, the
Preschool Program will also close for at least the first day. When the schools have a delayed
opening, the Preschool Program will have a delayed opening. For example, if the preschool is
delayed for one hour, we will open at 8:30 a.m. On a two hour delay, we will open at
9:30 a.m. In the event of inclement weather, please check WYFF, as well as the Augusta
Road Baptist Church website, app, and social media. When possible, an email may also be
sent to parents informing them of the need to close or open on a delayed schedule. Please
understand that GCS eLearning capabilities will allow the district to potentially close for longer
than normal. If ARBC believes we can safely open during such weather conditions, even if
GCS does not, we will.
Discipline Policy - Consistent, clear rules are explained, taught, and modeled to the children
at the beginning of the school year and reinforced continuously. Our staff uses a positive
approach to discipline and practices behavior management techniques. These include
communicating with positive statements and with children on their level, providing alternatives
and redirecting children, and providing appropriate words to help solve conflicts.
behavior endangers the safety of the children around him/her, or is abusive toward staff and
will not respond to our strategies listed above, the Director has the right to request that a
parent pick up their child for the rest of the day. A parent conference will be set up with the
director so we can partner with parent
behavior. If the behavior continues, the Director has the right to dismiss the child from the
preschool.
Dismissal of a Child - The Preschool Program reserves the right to dismiss any child. Reasons
for dismissal may include:
     1. She/he seems unable to participate in the group experience.
     2. She/he is unable to be effectively managed within our classroom setting.
     3. Parent or guardian does not abide by the policies, procedures, or shows disrespectful
        demeanor towards the staff of the preschool.
     4. Fees have not been paid.
Child Protection Policy - In order to protect ARBC staff, volunteers and program participants,
at no time will a staff person be alone with a single child where others cannot observe him or
her.

                                                                                                8
Emergency Plan
  ● Fire - Emergency notebook in hand, teachers and children will exit the building and
      will not return to the building until told to do so by the Director or designated staff
      person. Evacuation sites are the lower field and the far end of the playground.
  ● Tornado - Children will be taken off the Preschool hallway by the teachers and all will
      remain sheltered in place until the emergency has passed. Shelters include stairwells
      and the hallway by the main office. If the class is in the gym, the children and teachers
      will shelter in the bathrooms near the gym.

                                                                                              9
Medical Policies of the Preschool Program

For the safety and health of all students, the Preschool Program can only accept well children.
The Preschool Program is not equipped or staffed to provide care for sick children.
Cooperation of parents in helping prevent the spread of communicable diseases is expected
in order to protect the health and safety of our students. Parents should keep their child home
if they are not well. Please call us if you have questions about bringing your child.

PLEASE NOTIFY THE CENTER IMMEDIATELY: If your child has been diagnosed with a
communicable disease, such as COVID-19, chicken pox, RSV, pneumonia, pink eye, thrush,
Fifths disease, hand, foot, and mouth disease, measles, whooping cough, etc. We have a
responsibility to share this information with other parents and teachers in the center. Additional
sanitizing may be required. Your child may return when they are no longer contagious. The
center policy is not to reimburse for absences due to illness.

Listed below are symptoms of illnesses and the DHEC regulations regarding attendance at the
ARBC Preschool Program. Please remember the regulations are established to keep all
children healthy. Your child must be kept at home when he/she is exhibiting any of the
following symptoms:
     ● Fever - when a child has a temperature greater than or equal to 100 degrees
        Fahrenheit rectal he/she should remain home. When a child has a sublingual (by
        mouth) of 100 or axillary (under the arm) temperature of 99 degrees he/she should
        stay home. If a child develops a fever while in our care, parents will be notified to
        come and pick the child up. When a parent cannot be reached, we will call the
        designated local emergency contact. The child may return to the Preschool Program
        when he/she has been fever free for 24 hours without the aid of medication such as
        Tylenol or Motrin. See specific fever requirements pertaining to COVID-19 in the
        following section.
     ● Symptoms of Possible Severe Illness - Symptoms such as unusual lethargy, irritability,
        persistent crying, difficulty breathing, or other unusual symptoms or physical behavior
        may be signs of a more serious illness. Medical evaluation should be performed
        immediately by a physician to determine the cause.
     ● Diarrhea - Defined as two or three bowel movements in an eight hour period
        (including diarrhea at home) can be caused by infection, diet, or medication. If a
        child has diarrhea for any of the above reason, he/she should not come to school.
        Parents will be called to come for him/her if the child is already in attendance.

                                                                                               10
Although the frequent bowel movements may not represent a contagious condition, the
    percentage of time that the teacher spends with toileting needs to be considered.
●   Vomiting - Children with two or more episodes of vomiting in the previous 24 hours
    should stay home. Children who vomit at school will be asked to be picked up
    immediately. Children may return when vomiting resolves or a physician determines it
    to be non-communicable and the child is not in danger of dehydration.
●   Mouth Sores - when accompanied by drooling, child shall stay home until a physician
    or health official determines the condition to be non-infectious.
●   Rash - When accompanied with a fever or behavior change, child shall stay at home
    until a physician determines that it is not a communicable disease.
●   Purulent Conjunctivitis (pink eye) - Defined as pink or red conjunctiva with white or
    yellow discharge. Children may return 24 hours after treatment has been initiated.
●   Scabies, Head Lice, or other Infestations - Child shall stay home until 24 hours after
    treatment has been initiated.
●   Tuberculosis - Child shall be kept home until physician or health official states child
    can attend school.
●   Impetigo - Child shall stay home until 24 hours after treatment has been initiated.
●   Strep Throat - Child shall stay home until 24 hours after treatment has been initiated
    and the child is fever free for 24 hours.
●   Pinworm or Ringworm Infection - Child shall stay home until 24 hours after treatment
    has been initiated.
●   Chicken Pox - Child shall stay home until six days after onset of rash or until all lesions
    have dried and crusted.
●   Pertussis/Whooping Cough - Child may return to school after completing five days of
    prescribed antibiotics.
●   Mumps - Child may return nine days after onset of parotid gland swelling
●   Hepatitis A Virus - Child may not return until one week after onset of illness or as
    directed by the health department when passive antibody preparations has been
    administered to appropriate children and staff in the program.
●   Respiratory Syncytial Virus (RSV) - Child shall stay home until physician or health
    official states child can attend school. Please send the director a doctor s note.
●   Hand, foot, and mouth- Child may return when no new blisters and sores are present.
    All current blisters must be dried out and scabbed over. Child may not return if blisters
    are fluid-filled. Child shall stay at home until fever free for 24 hours. HFMD can be
    painful due to mouth sores and skin blisters. Children should be able to eat, drink, and
    play as normal, without pain medication, in order to be return.

                                                                                            11
Your child will be excluded from the facility if he/she has been determined by the local health
official or physician that he/she is contributing to the transmission of an illness during an
identified outbreak of any communicable illness at the facility.

Your child may attend with respiratory illness (symptoms of mild or moderate severity without
fever associated with the common cold, croup, bronchitis, and ear infections) as long as the
child is fever free for 24 hours and feels well enough to participate in classroom
activities.

Medication Policy - Prescription drugs and other medication required for a child must be in
the original container and clearly labeled with the child's name and dosage schedule. Please
fill out a medication form with dosage and times for teacher, and sign your name. Official
             instructions must accompany all medications to be administered. We cannot give
Motrin, Tylenol, or similar products for fever. All medications will be kept in a locked cabinet

                  Updated Preschool Wellness Procedures due to COVID-19

Reopening Procedures
   Parents will use the drive thru lane under the portico for their child to be dropped off
     outside the preschool with a staff member and then taken to his/her classroom. Drop-off
     in the morning is 7:30 a.m.- 8:30 a.m. using the drive thru lane. If you drop off after
     this time, please park in the lot and wait in the lobby until the director or teacher comes
     to take child to the classroom. No parents will be allowed onto the preschool hall at
     any time. To minimize the number of people in the lobby for safe distancing and to
     minimize contamination, we ask that parents only come into the preschool lobby if
     absolutely necessary.
   Parents will use this same process to pick up children in the afternoon. Pick up is 4:30
     p.m. - 6:00 p.m. Again, this will ensure fewer parents are coming inside the lobby. If
     you would like to pick up your child prior to 4:30 p.m., please message
     teacher so they can arrange it.
   We will be allowing minimal extracurricular activities this year. Outside therapies and
     services will be allowed on a case-by-case basis. All visitors will adhere to our wellness
     policies while on campus.
   Teachers and staff will wear masks.
   It is our priority to continue cohorting classes while inside the preschool building.
   Temperatures will be taken before entry to the preschool for all staff and children. A
     person with a temperature of 100 degrees Fahrenheit or higher will not be admitted.

                                                                                             12
Medical Policy Updates
  Any child with a temperature of 100 degrees Fahrenheit will be removed from their
    classroom immediately. Parents will be contacted to pick up their child. The child may
    not return to school until he/she is fever free for 24-hours without the use of any fever-
    reducing medication. Siblings of children with a temperature excluding them from ARBC
    will also be required to stay at home until sibling is readmitted.
  There is a series of screening questions that should be reviewed each morning before
    dropping off your child. Please answer these questions truthfully and honestly.
  If your child or a household member contracts COVID-19 or comes in contact with
    someone with a confirmed diagnosis of COVID-19 or is under investigation for COVID-
    19, it is your responsibility to let the Preschool Director know immediately and refrain
    from sending your child to ARBC.
  Screening Questions for Parents on COVID-19

Please look to the ARBC Preschool website for the most updated health and wellness
guidelines and information

                                         Church Staff

                            Rev. W. Mattison King, Senior Pastor
                           Dr. Barry L. Combs, Minister of Music
                          Rev. Bridget Kokolis, Minister to Families
                                 Jane Harrison, Church Pianist
                                   Clinton Flowers, Organist
                       Mandy Anderson, Director - Preschool Program
               Bridget Kokolis, Director - Afterschool & Summer Camp Program
                          Laura Walker, Communications Assistant
                             Cordell Golden, Facilities Manager

                                                                                           13
2021-2022 ARBC Preschool Program Calendar

The school year begins August 16, 2021. It is a year-round program open Monday thru
Friday, from 7:30 a.m. 6:00 p.m., with early-stay from 7:30 a.m. 8:30 a.m. for those
who need it. The Preschool Program does not prorate for holidays, illnesses, family vacation,
inclement weather, family vacations, in-service days, early closings or late openings, illness of
the child, unforeseen public health concerns, or withdrawal. The following is a list of important
dates and closings for the upcoming school year. Note that days the preschool is closed are
listed in red.

August 11             Last day of 2020-2021 classes
August 12,13          Closed for Teacher Workdays
August 15             Meet the Teacher 2:00 p.m. -- 4:00 p.m.
                      More information to be provided
August 16             FIRST DAY OF THE 2021-2022 SCHOOL YEAR
September 6           Closed Labor Day Holiday
October 29            Halloween Parade - More information to come
November 24-26        Closed Thanksgiving Holiday
December 22-24        Closed Christmas Holiday
December 30, 31       Closed for New Year's Holiday
January 17            Closed MLK Holiday
February 14           Treats for Teachers - Parent Support / Sign-up Genius
April 15              Closed Good Friday
May 2-6               Teacher Appreciation Week - Parent Support
May 30                Closed Memorial Day Holiday
June 2, 3             Closed for Teacher Workdays
July 4                Closed Independence Day
August 10             Last day of 2020-2021 classes
August 11,12          Closed for Teacher Workdays

                                                                                              14
Financial Policy of ARBC Preschool Program

Monthly tuition fees are invoiced on the 1st of each month and are due by the 10th. A late fee
of $30 will be assessed if not paid in full by the 10th. In order to continue attending the
preschool program, the tuition and late fee must be paid within two weeks of receiving your
late notice. Tuition may be paid online, by check, or account draft. No cash payments will
be accepted. Tuition will not be prorated for inclement weather, family vacations, in-service
days, early closings or late openings, illness, public health related closings like COVID-19 or
withdrawal. All active church members will receive a 15% discount on preschool tuition.

If you need to pay on a different day of the month you must present, in writing, a letter
requesting permission to do so. This letter must be submitted one week prior to the first of the
month for which tuition is due. The Director will inform you within one week if your request
has been approved.

Tuition is paid online and receipts are emailed when payments are processed. Please contact
us if you do not receive your monthly invoice or receipt. Annual receipts are given to all active
students and former students via email.

The Preschool Program closes daily at 6:00 p.m. A late fee of $1.00 per minute will begin
at 6:01p.m. if your child has not been picked up. If your child is registered for pickup at the
4:00 p.m. time, and you pick up late, we will assess the same $1.00 per minute fee after
these pickup times.

If late pickup occurs more than three times in an academic year, a $100.00 fee will be
assessed which must be paid before the child will be readmitted. Please be courteous of
                                                                    close their rooms at 6:00
p.m. and ensure proper cleaning, sanitation, and setup for the following day.

The Preschool Program is a year-round program and you are financially obligated to pay the
monthly tuition the entire year, including summer. If you need to take your child out of the
                                                                         our program. The
monthly fee must continue to be paid in order for your child's classroom spot to be held until
he/she returns to the program.

                              1-2022 academic year begins August 16, 2021.

                                                                                              15
2021-2022 ARBC Preschool Program
               Parent Handbook & Financial Obligation
                    Acknowledgment / Agreement

This acknowledgment and agreement is to be signed by both parents and/or guardians and
returned to the ARBC Preschool office.

I/We have read the ARBC Preschool Program Handbook and the policies and procedures
contained within it. I/We agree to abide by the terms outlined within this handbook and
acknowledge that failing to abide by them may result in my/our
program.

_______________________________________         ___________________________
Name (Printed)                                   Relationship to Child

_______________________________________         ___________________________
Signature                                        Date:

_______________________________________         __________________________
Name (Printed)                                  Relationship to Child

_______________________________________         __________________________
Signature                                       Date:

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