CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

Ohio Department of Job and Family Services
CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

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This form shall be completed prior to the child's first day of attendance and updated annually and as needed.
Child's Name
Date of Birth

MonthDayYear
Date
First Day at Program/Home
Address

Home Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
Home Telephone Number
Parent/Guardian Name #1
Relationship to Child
Address Same as Child's

Same as child's
Address (if NOT the same as child)

Parent's Work/School Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City
State
Zip
Home Telephone Same as Child's

Same as child's
Home Telephone Number (if NOT same as child)
Cell Phone (if applicable)
Email Address (if applicable)
example@example.com
Parent's Work/School Name
Parent's Work/School Telephone Number
Parent's Work/School Address

Parent's Work/School Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please indicate if this name should be released if a parent/guardian, of a child attending the center/home, requests contact information for other parents/guardians.

YesNo
If you answered yes, please indicate which number(s) above to include on the list

WorkCellHomeEmail
Where can you be reached while your child is in this program/home?
Parent/Guardian Name #2
Relationship to Child
Home Address

Same as Child's
Address (if address is NOT the same as child)

Second Parent's Work/School Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip
Phone Number

Same as Child's
Phone Number (If not same as child)
Cellphone Number
Email Address (if applicable)Number
example@example.com
Parent's Work/School Name
Parent's Work/School Telephone Number
Address

Parent's Work/School Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please indicate if this name should be released if a parent/guardian, of a child attending the program/home, requests contact information for other parents/guardians.

YesNo
If you answered yes, please indicate which information above to include on the list.

WorkCellHomeEmail
Where can you be reached while your child is in this program/home?
Emergency Contacts:

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.
First Emergency Contact
Full Name
City
State
Phone Number for First Emergency Contact
Relationship to Child
Other numbers where emergency contact can be reached (if applicable)
Second Emergency Contact
Full Name
City
State
Other numbers where emergency contact can be reached (if applicable)
Relationship to Child
Other numbers where emergency contactcan be reached (if
Name of Physician or Clinic/Hospital
Street Address
City
State
Telephone Number
Allergies, Special Health or Medical Conditions, and Food Supplements

Fill in this section accurately and completely. Please note that if your child has a current health or medical condition requiring child care staff to perform child specific care, such as: to monitor the condition, provide treatment, care, or to give medication, the JFS 01236 "Medical/Physical Care Plan" or equivalent form and/or the JFS 01217 "Request for Administration of Medication" must be completed and be kept on file at the center or family child care home.
Child is Name
Does your child have any food, medication, or environmental allergies? (check all that apply)

NoYes (check all that apply)Food (Peanuts, Oranges, etc.)Medication (Neosporin, Tylenol, etc.)Environmental (Dogs, Cats, etc.)
Please list and explain
Does your child's allergy/allergies require child care staff to monitor your child for symptoms to take action if a reaction occurs, or give emergency medication to your child? (check one)

NoYes - a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed.
Does your child have a developmental delay or special health or medical condition? (check one)

NoYes (Please explain)
Yes-please explain
Does the special health or medical condition require childcare staff to perform a procedure, or perform child specific care such a: to monitor your child for symptoms or administer medication during child care hours? (check one)

NoYes a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed.
Is your child currently using any medication of medical food? (check one)

NoYes please explain
Yes-please explain
If yes, does this medical food need to be administered at the child care program/home?

NoYes - a JFS 01217 "Request for Administration of Medication" must be completed and kept on file for each medication and a JFS 01236 "Child Medical/Physical Plan for Child Care" must be completed for the medical food.
Does your Child have any dietary restrictions, including those for medical, religious or cultural reasons? (check on)

NoYes - please explain
Yes - please explain
Does this dietary restriction require a modified diet that eleminates all types of fluid mild or an entire food group?

NoYes - written instructions from the child's health care provider must be on file.N/A - program does not provide meals or snacks to the child.
Child's Name
List any history of hospitalization, outpatient surgery. or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation.

Not applicable
If applicable, list hospitalization, outpatient surgeries here!
List any additional information about your child that would be useful for staff to know. such as fears or ways that your child prefers to be comforted.

Not applicable
If applicable, List additional information (fears, etc)
List any additional information about your child that would be useful for staff to know, such as eating or sleeping habits.

Not applicable
If applicable List additional information (eating or sleeping) habits.
List any additional information about your child that would be useful for staff to know. such as special routines. or behavior needs.

Not applicable
If applicable, list any additional information (special routines, behaviors, etc.)
Child's Name
Is your child toilet trained?

Yes (If Yes, skip to Emergency Transportation Authorization section)No (If No, fill out the following)
Diapering Statement
The program's policy is to check diapers every 2 hours. Please indicate if you want your child's diaper checked according to the program's policy or the other.

I agree with the program's scheduleI do not agree. please check my child's diaper every hour to half-hour.
Emergency Transportation Authorization
If You Do Not Give Permission to Transport

*I LOVE... DOES NOT EXCEPT CHILDREN WE CAN NOT TRANSPORT!!!
Program or Home Name
has permission to secure emergency transportation for my child in the event of an illness or injurywhich requires emergency treatment The emergency transportation service will determine the facility to which my child will be transported.
Parent's Signature

Clear
Date

MonthDayYear
Date
Acknowledgement of Policies and Procedures
I have reviewed and received a copy of the program's or home's policies and procedures/handbook

YesNo
This form, after being completed and signed by the parent/guardian, mustbe reviewed for completeness and signed by the dministrator/designee prior to the child receiving care.
Parent/Guardian Signature(s)

Clear
Date

MonthDayYear
Date
The form is to be initialed and dated, at least annually, after it has been reviewed by the parent/guardian. This is to indicate all information has stayed the same or changes have been noted. If significant changes are needed, please complete a new form. Parent/Guardian Initials Date of Review Administrator/Designee Initials Date of Review. See administrator for review initialing!
Note: This is a prescribed form which must be used by child care providers to meet the requirements to rules: 5101:2-12-15, 5101:2-13-15, and 5101:2-14-04. This form must be on file at the program or home on or before the child's first day of attendance and thereafter while the child is enrolled!
Should be Empty:

CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

Emergency Contacts:

Allergies, Special Health or Medical Conditions, and Food Supplements

Diapering Statement

Emergency Transportation Authorization

Acknowledgement of Policies and Procedures