CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

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 able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.

Allergies, Special Health or Medical Conditions, and Medical Foods

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 "Child Medical/Physical Care Plan for Child Care" must be completed and be kept on file at the program/home.

Please use this section to add those individuals to whom you are giving permission to pick up your child from care. Previously listed Parent/Guardian and Emergency contacts are already authorized.

Permission to photograph/video

Occasionally, Kids Encounter staff takes pictures of the children during normal classroom activities, special occasions, field trips, etc. in order to provide pictured records and memories of these events. In order for a child to have his/her photograph taken, we must have a consent form on file.

By signing this form, I state that I understand and agree that my child (whose name is listed above) may be photographed and/or videoed while under the care of Kids Encounter. I understand and agree that these photos/videos may be used in newsletters and/or the Kids Encounter website/Facebook.