One To Grow On 2 CHILD CARE ENROLLMENT FORM

MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES SECTION FOR CHILD CARE REGULATION BUREAU OF COMMUNITY FOOD & NUTRITION ASSISTANCE
One To Grow On
CHILD CARE ENROLLMENT FORM
FACILITY/PROVIDER NAME*
ADMISSION DATE*

MonthDayYear
Date
DISCHARGE DATE

MonthDayYear
Date
CHILD’S NAME*
CHILD'S GENDER*
CHILD'S BIRTHDATE*

MonthDayYear
Date
CHILD'S ADDRESS (STREET, CITY, STATE, ZIP CODE)*
IDENTIFYING INFORMATION
MOTHER’S/GUARDIAN’S NAME*
MOTHER’S/GUARDIAN’S NAME

ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF SAME AS ABOVE
HOME TELEPHONE NUMBER*
ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF SAME AS ABOVE*
CELL PHONE NUMBER*
E-MAIL ADDRESS*
example@example.com
EMPLOYER OR SCHOOL ATTEND*
WORK/SCHOOL SCHEDULE*
EXAMPLE: M-F 7AM-4PM
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE)*
WORK TELEPHONE NUMBER*
FATHER’S/GUARDIAN’S NAME
FATHER’S/GUARDIAN’S NAME

ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF SAME AS ABOVE
HOME TELEPHONE NUMBER
ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF SAME AS ABOVE
CELL PHONE NUMBER
E-MAIL ADDRESS
example@example.com
EMPLOYER OR SCHOOL ATTEND
WORK/SCHOOL SCHEDULE
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE)
WORK TELEPHONE NUMBER
EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY
(OTHER THAN PARENT) AT LEAST ONE EMERGENCY CONTACT IS REQUIRED.
NAME*
RELATIONSHIP TO CHILD*
TELEPHONE NUMBERS (CELL, WORK, HOME)*
ADDRESS (STREET, CITY, STATE, ZIP CODE)*
NAME
RELATIONSHIP TO CHILD
TELEPHONE NUMBERS (CELL, WORK, HOME)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
COMMENTS ON CHILD’S DEVELOPMENT
(PERSONAL DEVELOPMENT, BEHAVIOR, PATTERNS, HABITS, & INDIVIDUAL NEEDS)
RELATED CHILD*

YESNO
HOW IS CHILD RELATED TO CHILD CARE PROVIDER?
CHILD’S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED
CHECK HERE WHAT DAYS THE CHILD WILL ATTEND. WILL CHILD ATTEND:*

FULL TIME ORPART TIME
CACFP REQUIREMENT*

MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAYSUNDAY
WRITE ANY COMMENTS, CHANGES OR VARIATIONS IN USUAL ATTENDANCE IN THIS SECTION INCLUDING SHIFT CHANGES.
MONDAY: Child usually arrives?
EXAMPLE: 6AM , 6PM
MONDAY: Child usually leaves?
EXAMPLE: 6AM , 6PM
TUESDAY: Child usually arrives?
EXAMPLE: 6AM , 6PM
TUESDAY: Child usually leaves?
EXAMPLE: 6AM , 6PM
WEDNESDAY: Child usually arrives?
EXAMPLE: 6AM , 6PM
WEDNESDAY: Child usually leaves?
EXAMPLE: 6AM , 6PM
THURSDAY: Child usually arrives?
EXAMPLE: 6AM , 6PM
THURSDAY: Child usually leaves?
EXAMPLE: 6AM , 6PM
FRIDAY: Child usually arrives?
EXAMPLE: 6AM , 6PM
FRIDAY: Child usually leaves?
EXAMPLE: 6AM , 6PM
SATURDAY: Child usually arrives?
EXAMPLE: 6AM , 6PM
SATURDAY: Child usually leaves?
EXAMPLE: 6AM , 6PM
SUNDAY: Child usually arrives?
EXAMPLE: 6AM , 6PM
SUNDAY: Child usually leaves?
EXAMPLE: 6AM , 6PM
MO 580-2994 (10-18)
SCCR/CACFP
CHECK THE MEALS YOUR CHILD IS USUALLY GIVEN AT THIS FACILITY

BREAKFASTMORNING SNACKLUNCHAFTERNOON SNACKSUPPEREVENING SNACKNONE
CHECK THE HOLIDAYS YOUR CHILD IS IN CARE AT THIS FACILITY
CACFP REQUIREMENT

NEW YEARS’S DAY (JANUARY)MARTIN LUTHER KING JR.’S BIRTHDAY (JANUARY)PRESIDENT’S DAY (FEBRUARY)EASTER (MARCH/APRIL)MEMORIAL DAY (MAY)INDEPENDENCE DAY (JULY)LABOR DAY (SEPTEMBER)COLUMBUS DAY (OCTOBER)VETERANS DAY (NOVEMBER)ELECTION DAY (NOVEMBER)THANKSGIVING (NOVEMBER)CHRISTMAS DAY (DECEMBER)
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE OF AN EMERGENCY WITH MY CHILD, AND I WILL MAKE ARRANGEMENTS FOR MEDICAL CARE OF MY CHILD WITH THE PHYSICIAN OR HOSPITAL OF MY CHOICE.
IF I CANNOT BE REACHED TO MAKE NECESSARY ARRANGEMENTS, OR IN A CRITICAL EMERGENCY REQUIRING MEDICAL CARE, I AUTHORIZE
DAY CARE PROVIDER OR HOME PROVIDER
One To Grow On
TO CONTACT THE FOLLOWING:
PHYSICIAN OR CLINIC
NAME*
TELEPHONE NUMBER*
PREFERRED HOSPITAL
NAME*
TELEPHONE NUMBER*
ACKNOWLEDGEMENTS
I HAVE RECEIVED A COPY OF THIS FACILITY’S POLICIES PERTAINING TO THE ADMISSION, CARE A AND DISCHARGE OF CHILDREN.
PARENT/GUARDIAN INITIALS*
I HAVE BEEN INFORMED THAT A COPY OF THE LICENSING RULES FOR CHILD CARE HOMES OR THE LICENSING RULES FOR GROUP CHILD CARE HOMES AND CENTERS IS AVAILABLE AT THIS FACILITY FOR B REVIEW.
PARENT/GUARDIAN INITIALS*
THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING COMMUNICATION REGARDING C MY CHILD’S DEVELOPMENT, BEHAVIOR, AND INDIVIDUAL NEEDS.
PARENT/GUARDIAN INITIALS*
WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE ACCEPTED FOR D CARE OR REMAIN IN CARE.
PARENT/GUARDIAN INITIALS*
I UNDERSTAND THAT, BEFORE THE FIRST DAY OF ATTENDANCE BY MY CHILD, I WILL PROVIDE PROOF E OF COMPLETED AGE-APPROPRIATE IMMUNIZATIONS OR EXEMPTION FROM IMMUNIZATIONS.
PARENT/GUARDIAN INITIALS*
H*

I DOI DO NOT GIVE PERMISSION FOR FIELD TRIPS/EXCURSIONS. I UNDERSTAND I WILL BE NOTIFIED IN ADVANCE WHEN THEY ARE PLANNED.
PARENT/GUARDIAN INITIALS*
G*

I DOI DO NOT GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD.
PARENT/GUARDIAN INITIALS*
I HAVE BEEN INFORMED AND HAVE RECEIVED A COPY OF THE FACILITY’S SAFE SLEEP POLICY WHEN H ENROLLING A CHILD LESS THAN ONE (1) YEAR OF AGE.
PARENT/GUARDIAN INITIALS*
I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENT OR ANY TIME THERE I AFTER WHETHER THERE ARE CHILDREN CURRENTLY ENROLLED IN OR ATTENDING THE FACILITY FOR WHOM AN IMMUNIZATION EXEMPTION HAS BEEN FILED.
PARENT/GUARDIAN INITIALS*
PARENT’S/GUARDIAN’S SIGNATURE
Signature*

Clear
DATE
Date

MonthDayYear
Date
MO 580-2994 (10-18)
SCCR/CACFP
Should be Empty:

MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES SECTION FOR CHILD CARE REGULATION BUREAU OF COMMUNITY FOOD & NUTRITION ASSISTANCE

One To Grow On

CHILD CARE ENROLLMENT FORM

IDENTIFYING INFORMATION

EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY

COMMENTS ON CHILD’S DEVELOPMENT

CHILD’S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED

CHECK THE HOLIDAYS YOUR CHILD IS IN CARE AT THIS FACILITY

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

PHYSICIAN OR CLINIC

PREFERRED HOSPITAL

ACKNOWLEDGEMENTS