CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

Ohio Department of Job and Family Services

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

Please indicate if this name should be released if a parentiguardian, of a child attending the program/home requests contact information for other parents/guardians.YesNo Email Home Cell# Work # If you answered yes, please indicate which information above to include on the list Where can you be reached while your child is in this program/home?

Please indicate if this name should be released ifa parentiguardian, of a child attending the program/home, requests contactinformation No Yes for other parents/guardians. Home #Email Cell# Work # If you answered yes, please indicate whichinformation above to include on the list Where can you be reached while your child is in this program/home?

Emergency Contacts: Parents cannot be Jisted as emergency contacts. List the name of at least one person who can be contacted in the eventof an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one personilisted mustbe able to take responsibility for the child in case the parent/guardian cannotbe contacted and should be at least 18 years of age. Name Name

Other numbers where emergency contact can be reached (if applicable) Name of Physician or Clinic/Hospital

Other numberswhere emergency contacte can be reached (if applicable)

Allergies, Special Health or Medical Conditions, and Medical Foods Fill in this section accurately and completely. Please note that if your child hasa current healther medical condition requiring child care "Child Medical/Physical Care Plan for Child Care" mustbe completed and be kept on file at the program/home. Does your child have any food, medication or environmental allergies? (check all that apply) No Please list and explain: Environmental FoodMedication Yes check all' that apply

Does your child's allergy/allergies require child care staff to monitor your child for symptoms to take action ifa reaction occurs, or give emergency medication to your child? (check one) Yes a JFS 01236 "Child hysical Care Plan for Child Care" must be completed Does your child have a developmental delay or special health or medical condition? (check one) No Yes please explain

Does the specialhealth or medical condition require child care staff to perform a procedure, or perform child specificare suchas: to monitor your child for symptoms or administer medication during child care hours? (check tone) No Yes a JFS 01236 "Child Medical/Physical Care Plan for Child Care" 'must be completed is your child currently using any medication or medical food? (check one) No Yes please explain

# yes, does this medication or medical food need to be administered at the child care program/home? Noa JFS 01217 "Request for Administration of Medication" 'mustibe completed and kept on file for each medication and a JFS Yes 01236 "Child Medical/Physical Care Plan for Child Care" 'mustbe completed for the medical food. Does your child have any dietary restrictions, including those for medical, religious or cultural reasons? (check one) No Yes please explain

Does this dietary restriction require a modified dietth teliminates all types of fluid milk or an entire food group? No Yes written instructions from the child's health care provider mustbe on file. N/A program does not provide meals or snacks to the child.

Diapering Statement Yes (If yes, skip to Emergency Transportation Authorization section) No (If no, fill lout the following:)

The program's policy is to check diapers every program's policy or another: I agree with the program's schedule

hours. Please indicate if you wantyour child's diaper checked according to the

Ido not agree, please check my child's diaper every Emergency Transportation Authorization

Do Not Give Permission to Transport

Program or Home Name The Learning Ladder Academy has permission to secure emergency transportation for mychild in the event of an illness or injurywhich requires emergency treatment. The emergency transportation service will determine the facilityto which my child will be transported.

does not have permission to secure emergency transportation for my child in the event of an illness or injury Dowhich requires emergency treatment. Iwishfor the following not actionto be taken: sign both

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

This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the Iministrator/designee prior to the child receiving care.

The form is to be initialed and dated, at least annually. afteri it has been reviewed by the parentiguardian. 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. Date of Review Administrator/Designee Initials Date of Review Parent/Guardian Initials

This This is formmust aprescribed 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.

Note: 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.

Ohio Department of Job and Family Services

Routine Trip Destination(s) to, from, home, walks, school Date of Permission (valid for one year)

Mode of Transportation (walking, school bus, public transportation, parent vehicles, provider vehicle and driver) varies

During this trip children will have access to water that is 18 inches or more in depth. Yes No Yes Are water activities planned in water that is 18 inches or more in depth? (if yes, a swimming permission sip is required) Child's Information Child's Name

not over 4 years and/or 40 lbs

I grant permission for my child to participate in the routine trips described above.

Child Pick-Up Form The following people HAVE permission to pick-up the child named below from The Learning Ladder Academy. It is the parent's responsibility to notify me in writing of any changes.

The following people MAY NOT pick-up my child(ren) from DAYCARE NAME.

Note: Any person unfamiliar to me will be required to show proof of identification. Under NO circumstances will the child be released to anyone other than those listed above without WRITTEN permission from the parent. This form is legally binding, so by signing it, you agree that all of the information provided herein is correct. False Information will result in termination of contract, and you will forfeit your childcare retainer.

The Learning Ladder Academy grant permission to hereinafter known as the "Media" to use my image (photographs and/or video) for use in Media publications including:

1-Videos

2-Email Blasts

3-Recruiting Brochures

4-Newsletters Magazines

5-General Publications

6-Website and/or Affiliates

7-Other

I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use isknown to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. Please initial the paragraph below which is applicable to your present situation:

 

Signature of parent or legal guardian: (if under 20 years of age)

(parent/guardian) have read and I agree to The Learning Ladder Academy policies and procedures stated in their handbook.