CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE
This form shall be completed prior to the child's first day of attendance and updated annually and as needed.
Childs Name*
Date of Birth*

MonthDayYear
Date
First Day at ProgramHome
Address*

Home Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State*
Zip Code*
Home Telephone Number*
ParentGuardian Name 1*
Relationship to Child*
City*
State*
Zip*
Email Address if applicable*
example@example.com
Cellphone Number*
Parents Work/School Name*
Parent's work phone*
Parent work Address*

Parents WorkSchool 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 listWork #Cell #Home #Email
Where can you be reached while your child is in this program home*
Parent/Guardian Name 2*
Relationship to Child*
City
State
Zip
Email Address if applicable*
example@example.com
Parents WorkSchool Name
Parent #2 Cellphone*
Address

Parents WorkSchool Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City
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 listWork #Cell #Email
Where can you be reached while your child is in this program *
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.
Name*
Relationship to Child
Telephone number*
Other numbers where emergency contact can be reached if applicable*
City
State
Name*
Telephone number*
Other numbers where emergency contact can be reached if applicable*
City
State
Relationship to Child
Name of Physician or Clinic/Hospital*
Street Address
City
State
Telephone Number*
Child' Name*

First and Last Name
Does your child have any food, medication or environmental allergies? (Check all that apply)*

NoYes (check all that apply)FoodMedicationEnvironmental
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
Does your child have a developmental delay or special health or medical condition? (check one)*

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

NoYes
Is your child currently using any medication or medical food? (check one)*

NoYes
If yes, please explain:
If yes does this medication or medical food need to be administered at the child care program/home?*

NoYes
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons? (check one)*

NoYes
If yes, please explain:
Does the dietary restriction require a modified diet that eliminates all types of fuild milk or an entire food group?*

NoYes written restrictions from the child's health care provider must be on file.N/A program does not provide meals or snacks to the child.
Childs 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
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
List any additional information about your child that would be useful for staff to know such as eating or sleeping habits
Not applicable
List any additional information about your child that would be useful for staff to know such as special routines or behavior needs
Not applicable
Childs Name*
Is your child toilet changed?*

Yes (If yes, skip to Emergency Transportation Authorization sectionNo (If no, fill out the following:)
Please indicate if you want your child's diaper checked according to the center

I agree with the program's scheduleI do not agree, please check my child's diaper every
has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported. If you agree please sign and date.
Parents Signature*

Clear
does not have permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment I wish for the following action to be taken:
Date*

MonthDayYear
Date
Parents 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.Yes

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

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*

MonthDayYear
Date
Parent/Guardian Initials*
Date of Review*

MonthDayYear
Date
Note: This is a prescribed form which must be used by child care providers to meet the requirements to rules 5180:2-12-15, 5180:2-13-15, and 5180:2-14-04.

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.
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.
Child's Name*
DOB*
Sex
Name*
DL
Relation*
Address
Phone*
Name
DL
Relation
Address
Phone
Name
DL
Relation
Address
Phone
The following people MAY NOT pick-up my child(ren) from DAYCARE NAME,
Name
DL
Relation
Address
Phone
Name
DL
Relation
Address
Phone
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.
Father/Guardians Signature

Clear
Mother/Guardians Signature*

Clear
Date*

MonthDayYear
Date
PARENT/GUARDIAN REQUEST FOR FLUID MILK SUBSTITUTION
Parents or guardians may now request in writing that non-dairy beverages be substituted for fluid milk for their children with special dietary needs without providing statement from a recognized medical authority. However, fluid milk substitutions requested are at the option and expense of the facility/center.

The non-dairy beverage provided must be nutritionally equivalent to fluid milk and meet the nutritional standards set by the United States Department of Agriculture (USDA) for Child Nutrition Programs in order for the facility/center to claim reimbursement for the meal through the Child and Adult Care Food Program (CACFP

A non-dairy beverage product must at a minimum contain the following nutrient levels per cup to qualify as an acceptable milk substitution: a. Calcium 276 mgd. Vitamin D 100 IU g. Potassium 349 mg b. Protein 8 ge. Magnesium 24 mg h. Riboflavin .44 mg C. Vitamin A 500 IUf. Phosphorus 222 mg i. Vitamin B-12 1.1 mcg

To be completed by Child Care Center/Provider prior to distribution of form Name of Child Care Center/Provider:
To be completed by Parent/Guardian Child's Full Name:
Child's Full Name*
I request that my child is served the nondairy beverage which meets the USDA approved nutrient standards for a milk substitute that is provided by the centerprovider as indicated above
Identify the medical or other special dietary needs that restrict the diet of your child why your child needs a nondairy beverage as a milk substitute
I am aware that the center is not providing a nondairy beverage for the substitution of fluid milk I will provide a nondairy beverage for my child that meets the USDA approved nutrient standards for a milk substitute as stated above
I request that my child is served the non-dairy beverage which meets the USDA approved nutrient standards for a milk substitute that is provided by the center/provider as indicated above. I am aware that the center is not providing a non-dairy beverage for the substitution of fluid milk. I will provide a non-dairy beverage for my child that meets the USDA approved nutrient standards for a milk substitute as stated above.
I will provide a nondairy beverage for my child that does not meet the USDA approved nutrient standards for the substitution of fluid milk I understand that the center cannot claim meals that require milk unless I get a written statement from a recognized medical authority
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
Date
USDA Nondiscrimination Statement In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, nation al origin, sex, (including gender identity and sexual orientation) disability, age, or reprisal or retaliation for prior civil rights activity. Persons with disabilities who require alternate mcans of communication to obtain program information (c.g. Braille, large print, audiotape, American Sign Language, etc, should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: tps:/ www.usda.gov sites default/files or from any USDA office, by calling (866)-632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form letter must be submitted to USDA by (1) Mail: U.S. Department of Agriculture, Director, Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410; (2) Fax: (833) 256-1665 or (202) 690-7442 or (3) Email: Program.Intake@usda.gov

This institution is an equal opportunity provider.
MEDIA RELEASE FORM
Parent/Guardian Name*

First NameLast Name
grant permission to hereinafter known as the "Media" to use my image (photographs and/or video) for use in Media publications including:
Check all that apply

VideosEmail BlastsRecruiting BrochuresNewslettersMagazinesGeneral PublicationsWebsite and/or AffiliatesOther
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 is known 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:
I am 20 years of age or older and I am competent to contract in my own name I have read this release before signing below and I fully understand the contents meaning and impact of this release I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release
I am the parent or legal guardian of the below named child I have read this release before signing below and I fully understand the contents meaning and impact of this release I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release
Signature*

Clear
Date*

MonthDayYear
Date
Name please print*
Address
Signature of parent or legal guardian:
Signature of parent or legal guardian if under 20 years of age*

Clear
Parent/guardian name*
(parent/guardian) have read and I agree to The

Learning Ladder Academy policies and procedures stated in their
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

PARENT/GUARDIAN REQUEST FOR FLUID MILK SUBSTITUTION

MEDIA RELEASE FORM

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