Juneau Cooperative Nursery School

Semester: Fall or Winter

Year: ______

Name of Child _____________________________

Gender M or F
Birthdate ________________

Checklist

You must completely fill out the attached forms and include your check
payment.

________Intent to Register Form

________Medical Form
________Background Check Form
________Payment ($50 for each day requested, $25 for substitute spot)

Send to:
juneaucoopnursery@yahoo.com
JUNEAU CO-OP NURSERY SCHOOL
Intent-to-Register Form
Include a check for $50 payable to JCNS for your Semester Tuition Fee.
This fee is NON-REFUNDABLE, unless the program fills up before you get in.

Child’s Name _________________________________ Gender: M F Birthdate ___________________

Mailing Address ___________________________________________________________________

Name of participating parent _________________ Work phone _____________________________

E-mail address E-mail received at home or work? (Circle one)

Will another parent and/or caregiver ever be volunteering for Nursery? Yes No

If yes, Name of other volunteer ___________________________ Phone ____________ H or W?

Session Preference: For each possible session, please circle yes or no to indicate whether or
not you would be interested in attending. Then please rank the sessions from 1 (1st choice)
to 5 (last choice).

____ Monday 9:30 - Noon Yes No

____ Tuesday 9:30 - Noon Yes No
____ Wednesday 9:30 - Noon Yes No
____ Thursday 9:30 - Noon Yes No
____ Friday 9:30 – Noon Yes No

Substitute Preference: If no regular slot is open, would you accept a substitute slot? Yes No
Would you prefer to have a substitute slot rather than a regular slot? Yes No

Attending More Than Once a Week: How many days of the week would you like to attend? _____
(Each additional day requires $40 tuition and taking on another volunteer job.)

Previous Co-op Nursery Experience: What year? ______ # semesters? ____ Regular or Substitute?

Designated Representative: If you are unable to attend Registration Night, you may designate a person to change
which session your child is registered in based on group composition (i.e. age or gender balance). Who do you
choose as your designated representative? __________________________________________

Volunteer Job Preference: For each of the following volunteer jobs, please circle yes or no to indicate whether or
not you would be willing to do that job. Then please rank your top 5 choices.
____ Program Coordinator Yes No
____ Registration Coordinator Yes No
____ Treasurer Yes No
____ Group Coordinator Yes No (Need 5)
____ Secretary Yes No
____ Clean-up Leader Yes No (Need 3)
____ Member @ Large Yes No
____ Health & Safety Yes No
____ Repair & Maintenance Yes No
____ Toy Closet Yes No (Need 2)
____ Posting Flyers Yes No
____ Art Closet Yes No (Need 2)
____ Community Activities & Events Information Yes No
____ Snack & Cleaning Supplies Buyer Yes No
____ Playdough Maker & Sand /Water/Bean Table Yes No

Signature of Participating Parent: ____________________________________ Date: _________

Juneau Co-op Nursery School
MEDICAL FORM
This form is required to complete your registration for the program.

Name of Child ____________________________

Gender M F Birthdate __________________

How to reach parent(s) or legal guardian:
MOTHER ___________________________
Address _____________________________
Home phone __________________________
Work phone __________________________
Authorized to pick up child? _____________
FATHER ______________________________
Address _______________________________
Home phone ____________________________
Work phone ____________________________
Authorized to pick up child? _______________

People who are also authorized to pick up my child from school (indicate also if we can call them in an EMERGENCY if
parent(s) cannot be contacted):
Name _________________________ Relationship _____________________ Call in emergency? Y N
Address _________________________________ H phone _____________ W phone _____________

Name _________________________ Relationship _____________________ Call in emergency? Y N

Address _________________________________ H phone _____________ W phone _____________

Name _________________________ Relationship _____________________ Call in emergency? Y N

Address _________________________________ H phone _____________ W phone _____________

Child’s Doctor _______________________________ Phone ________________

Insurance Company _________________________ Group # _______________ ID# _______________

Allergic reactions to medications ____________________________________________________________

Describe any conditions requiring regular medication ____________________________________________

Food allergies ___________________________________________________________________________

Other foods that you do not wish child to eat ___________________________________________________

To what degree is your child potty-trained? ____________________________________________________

Any other special needs? _______________________________________________________________________

CONSENT FOR EMERGENCY MEDICAL OR SURGICAL CARE

This authorizes the Juneau Co-op Nursery School to give permission to any medical professional to provide emergency
medical or surgical care for _______________________________ in the event that I cannot be contacted immediately. It
is understood that a conscientious effort will be made to locate me or my spouse before any action will be taken. I
understand my obligation to keep the JCNS volunteers informed of my whereabouts. I will assume the cost of necessary
medical or surgical care.

__________________________________ ___________________________________
Signature of Parent or Legal Guardian Witness
Date: _________________ Date: ___________________

LIABILITY RELEASE
I hereby, for myself, my heirs, executors, and administrators, waive and release, and discharge any and all rights and
claims for damages I may have against the Juneau Co-op Nursery School and their respective agents, representatives,
successors or assignees for any and all injuries which may be suffered by my child in connection with the said Nursery
School.

____________________________________ ____________________
Signature of Parent or Legal Guardian Date
Juneau Co-op Nursery School
BACKGROUND CHECK FORM
This form must be completed by each adult volunteer who wants to work with the children
Your registration is not complete without this form.

Name of child __________________________

Your relationship to child ______________________
Your legal name ______________________________________________________________________
(First) (Middle) (Last)
Gender: M F Birthdate _________________ Social Security # ________________________

Mailing address ______________________________________________________________________

Residence address ___________________________________________________________________

Home phone ___________ Work phone ___________ How long have you lived in Juneau? _______

For the past ten years, list cities of residence and the years that you lived there:
City State Country What years?

List any names you have used in the past and the years that you used them:
Former name Used from when to when?

Have you:

1. Been arrested, adjudicated, or convicted of any crime relating to or involving minor children? ______

2. Been found to have sexually abused or exploited or physically abused any child or adult:
a) in any court action or proceeding? ____________
b) by a professional disciplinary or licensing board? ____________

3. Been the subject of a mental health involuntary commitment proceeding? _____________

4. Been denied a license to care for children or adults, or had a license suspended or rebuked? _________

5. Ever committed a criminal offense relating to or involving minor children? ___________

Include a statement of explanation on the back of this page for any “YES” answers or for any question you did not know
how to answer.

I hereby certify and affirm under penalty of perjury that the above information is true and correct to the best of my
knowledge. I understand that fraud or misrepresentation in my answers can serve as the basis for excluding my
participation in the Juneau Co-op Nursery School.

I hereby authorize the Juneau Co-op Nursery School to use this form to obtain information about me from the records of
law enforcement agencies. I hereby authorize these agencies to release information to the Juneau Co-op Nursery School
which relates to my suitability to supervise or have access to children.

I also understand that being under the influence of alcohol or illegal drugs while I am supervising the children in the
Juneau Co-op Nursery School will result in me being excluded from further participation in the program.

Signature __________________________________________ Date ________________

JUNEAU COOPERATIVE NURSERY SCHOOL
SEXUAL MISCONDUCT POLICY & PROCEDURES
It is the policy of the Juneau Cooperative Nursery School (JCNS) to provide a safe and nurturing
environment for children and their families. Actions that could be interpreted as having sexual intent,
or content, towards a child or caretaker will not be tolerated. Individuals who have a prior history of
sexual misconduct that has resulted in legal charges may not participate in the program. His or her
child may be registered provided another adult is available to be the child’s “working parent”.

Background Checks:

All adults who participate in the program are required to complete a background check form. A parent
may not work in the program until this form is completed. The Registration Coordinator will check
each adult participant against the State of Alaska Registration of Sexual Offenders at the beginning of
each semester. Individuals listed there, for whatever reason, may not participate as working parents
in the JCNS program.

Sexual Misconduct:

For the purposes of this policy, sexual misconduct will be defined as any action, inaction, or statement
that could be construed by a reasonable person to be inappropriate, offensive or to have a sexual
content.

Reporting Requirement:

Individuals who witness, or have reason to believe that anyone involved in the JCNS program has
engaged in sexual misconduct toward a child or caretaker are required to report their concerns directly
to the Program Coordinator, Registration Coordinator, or Treasurer.

Investigation:

Allegations of sexual misconduct will be investigated by at least two (2) members of the JCNS
Organization Committee. Every effort will be made to conduct a full and fair investigation into the
allegations. Allegations of misconduct will be kept confidential during the investigation. During the
course of the investigation, the individual against whom the charges are made will not be allowed to
participate or be physically present during JCNS operating hours. His or her child will be eligible to
participate in the program provide another adult can participate as that child’s “worker parent”.

If the allegations are sustained, the individual so charged will be barred from participating in the
program. His or her child will be eligible to participate in the program provided another adult is
available to participate as that child’s sponsor.

If the allegations are not sustained, the individual shall be allowed to return to the program as a full
member.